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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Ciprofloxacin HCl 500 mg PO Q12H
Stop on ___
3. Collagenase Ointment 1 Appl TP DAILY
4. Daptomycin 750 mg IV Q24H Duration: 6 Weeks
Proposed End date: ___
RX *daptomycin 500 mg 1.5 vials IV q24H Disp #*63 Vial
Refills:*0
5. Docusate Sodium 100 mg PO BID
stop taking if having loose stools
6. Enoxaparin Sodium 60 mg SC Q12H
Continue for 4 weeks
7. Gabapentin 300 mg PO TID
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID
stop taking if having loose stools
11. Vitamin D 5000 UNIT PO DAILY
12. Lisinopril 30 mg PO DAILY
13. ALPRAZolam 0.5 mg PO Q6H; PRN anxiety
14. lovastatin 20 mg oral qd
15. Metoprolol Tartrate 25 mg PO BID
16. TraZODone 100 mg PO QHS:PRN insomnia
17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you complete your course of Lovenox x
28 days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L knee dislocation, s/p L TKA reivsion; s/p left knee antibiotic
spacer exchange and gastro flap of left knee
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox 60 mg twice
daily for four (4) weeks to help prevent deep vein thrombosis
(blood clots).
9. WOUND CARE: Please keep dry sterile dressing in place until
follow-up visit next week with the Plastics team on ___. You
have 1 JP drain in place, which should remain in place until
your follow up with the Plastic Surgery & Reconstruction team.
All questions and concerns regarding wound care should be
directed to their office. See follow up appointment information
below.
10. ___ (once at home): Home ___, daily dressing changes and
wound checks as instructed by Plastics Surgery & Reconstruction
team.
11. ACTIVITY: Toe touch weight bearing on the operative
extremity. Two crutches or walker. Knee immobilizer in place at
all times. NO ROM. No strenuous exercise or heavy lifting until
follow up appointment.
12. PICC CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CPK
- CHEM 7
- LFTS
- ESR/CRP
**All questions regarding outpatient parenteral antibiotics
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Current OPAT regimen
Daptomycin 750 mg IV Q24H
Duration of OPAT regimen
Start date: ___
Stop date: ___
Physical Therapy:
***No Range of Motion LLE, knee immobilizer in place at all
times locked in extension***
Toe touch weight bearing LLE
Mobilize frequently***
Treatments Frequency:
**Stage 3 necrotic pressure ulcer of left buttock, s/p sharp
excisional debridement x2. Please perform daily dressing changes
as below.
Site: Left glut
Description: Type/Etiology/Stage: Unstageable pressure injury
Size: 4.2(L)x4.2(W)x2.0(D)cm, no tunneling or undermining. Wound
bed: 50% black/soft eschar and 50% pink/white mix tissue. No
fluctuance in wound bed. Wound edges: Unattached Exudate: Small
serosang Odor: None detected Periwound tissue: Partial thickness
opening extending from ___ o'clock position extending approx.
1cm otherwise blanching erythema. No warmth. Wound Pain: Mild
discomfort with cleansing, palpation
Care: s/p x2 bedside sharp debridement ___ and ___ with
general surgery team Topical therapy: Normal saline to cleanse
wound. Pat the tissue dry with dry gauze. Apply THIN layer of
criticaid clear barrier ointment to periwound skin (to protect)
Apply santyl ointment (nickel thick) to wound bed Gently pack
wound with BARELY MOISTENED (with normal saline) 2x2 gauze
Secure with pink hy tape (Manf #20) Change dressing daily.
Support surface: Mighty Air mattress in place
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times Waffle Boots ( x )
If OOB, limit sit time to one hour at a time and
Sit on a pressure redistribution cushion-
ROHO ( x ) Obtain from ___
OR ___ air full length chair cushion ( x) (Obtain from ___
Elevate ___ sitting.
Moisturize B/L ___ and feet, intact skin only BID with Sooth
And Cool Ointment.
*Dressing changes daily* -
Normal saline to cleanse wound.
Pat the tissue dry with dry gauze.
Apply THIN layer of criticaid clear barrier ointment to
periwound skin (to protect)
Apply santyl ointment (nickel thick) to wound bed
Gently pack wound with BARELY MOISTENED (with normal saline)
2x2 gauze
Secure with pink hy tape.
Change dressing daily.
Incontinence care:
Please avoid chucks under patient.
Cleanse area with commercial foam cleanser and soft disposable
cloth.
Apply THIN layer of criticaid clear barrier ointment daily and
every third cleansing.
Can use large softsorb to wick away liquid stool
Change daily and as needed.
**Please leave knee dressing and JP drain x1 in place until
follow up visit in clinic on ___, record output q4H**</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Labetalol 300 mg PO TID
3. leflunomide *NF* 20 mg Oral daily
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. Tacrolimus 3 mg PO QAM
6AM
6. Tacrolimus 2 mg PO QPM
6PM
7. Torsemide 100 mg PO DAILY
8. Rosuvastatin Calcium 5 mg PO DAILY hyperlipidemia
Hold if proximal muscle weakness, elevated CK
9. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qPM
10. Vitamin D 50,000 UNIT PO QMONTH
11. Glargine 13 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
12. Nephrocaps 1 CAP PO DAILY HD
RX *Nephrocaps 1 mg 1 Capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
13. Losartan Potassium 100 mg PO DAILY HTN
Hold for SBP<100.
RX *losartan 100 mg 1 Tablet(s) by mouth one time per day Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: graft thrombosis
secondary diagnosis: ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of ___ while ___ were hospitalized
at the ___ were transferred here because
your dialysis graft was not able to be accessed. ___ underwent
an imaging procedure called a fistulogram so that our
interventional radiologists could determine whether there was in
fact flow through your dialysis graft. When they discovered that
there was no flow because of a clot, they were able to perform a
procedure called a thrombectomy to remove the clot. The
thrombectomy was successful and the flow through your graft was
confirmed when ___ received hemodialysis on ___.
Your dialysis session went very well. Our nephrologists
recommended that ___ start vitamins called nephrocaps for
patients on hemodialysis. ___ may also need to start a
medication called erythropoietin with hemodialysis so to help
___ produce red blood cells.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Hold for loose stools.
4. Calcium Carbonate 500 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH HS
7. Lidocaine 5% Patch 1 PTCH TD QAM
Apply 12hrs on, 12hrs off.
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) place one patch in
your arm QAM Disp #*14 Each Refills:*0
8. Senna 17.2 mg PO HS
Hold for loose stools.
9. Simvastatin 10 mg PO DAILY
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg Half tablet(s) by mouth Q6hr-prn Disp #*56
Tablet Refills:*0
11. Vitamin D 800 UNIT PO DAILY
12. Metoprolol Tartrate 12.5 mg PO Q6H
13. Rivaroxaban 15 mg PO DINNER
RX *rivaroxaban [Xarelto] 15 mg One tablet(s) by mouth Daily
with the evening meal Disp #*30 Tablet Refills:*0
14. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg One capsule(s) by mouth Q6hr-prn Disp #*2
Capsule Refills:*0
15. removable long risk splint
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Subnodal block in the setting of Fixed His-Purkinje
Disease. s/p Pacemaker placement.
Secondary: Traumatic L distal ulnar fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Miss ___,
It was a pleasure to care for you at the ___
___. You were admitted for an intermittently very
slow heart rate causing you to have neurologic symptoms. We
believe that this slow heart rate likely caused you to fall,
precipitating your arm fracture. While here, you had a pacemaker
placed to maintain a normal heart rate. You were seen by
Orthopaedics who recommended a sling for your arm, but no
operative management. We prescribed you a lidocaine patch to
control your back pain.
Please see below for your medications and appointments. Thank
you for allowing us to participate in your care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *Cipro 500 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*25 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with appendicitis requiring an
operation to remove your appendix. You are being treated with a
course of antibiotics that you will need to complete as
directed.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. DiphenhydrAMINE 50 mg IV BID
RX *diphenhydramine in 0.9 % NaCl 50 mg/50 mL infuse 50mL of
50mg/50mL solution twice daily Disp #*3000 Milliliter Refills:*0
2. Pantoprazole 80 mg IV Q12H
RX *pantoprazole [Protonix] 40 mg infuse 40mg IV solution twice
daily Disp #*2400 Milligram Refills:*0
3. Doxycycline Hyclate 100 mg IV Q12H MRSA bacteremia,
suppression dose
day 1 is ___
RX *doxycycline hyclate 100 mg 100mg IV doxycycline twice daily
Disp #*600 Milligram Refills:*0
4. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
(Tunneled Access Line) 2 mL DWELL DAILY Not for IV use. To be
instilled into EACH central catheter port for local dwell daily
Right After TPN finishes in AM. Please leave in for 1.5-2 hrs,
then Aspirate and Flush with saline and heparin afterwards
5. Fentanyl Patch 75 mcg/h TP Q72H
RX *fentanyl [Duragesic] 75 mcg/hour Apply one to skin, change
every 72 hours Change every 72 hours Disp #*12 Transdermal Patch
Refills:*0
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. ___), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
RX *heparin lock flush (porcine) [Heparin Lock] 10 unit/mL
Instill 2mL of 10 unit/mL solution as needed Disp #*1000
Milliliter Refills:*0
7. TPN
Volume(ml/d) ___, Amino Acid(g/d) 100, Dextrose(g/d) 400,
Fat(g/d) 45. Trace Elements will be added daily. Standard Adult
Multivitamins will be added. NaCL 200, NaAc 115, NaPO4 0, KCl
50, KAc 10, KPO4 25, MgS04 32, CaGluc 8. Famotidine(mg) 100,
Zinc(mg) 15. Cycle over 18hrs. Start at 1800 Decrease rate to
half at 1100, Stop at 1200.
8. catheter dwell
Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
(Tunneled Access Line) 2 mL DWELL DAILY Not for IV use. To be
instilled into EACH central catheter port for local dwell daily
Right After TPN finishes in AM. Please leave in for 1.5-2 hrs,
then Aspirate and Flush with saline and heparin afterwards
Dispense 1000mL
Duration: Ongoing
9. Outpatient Lab Work
Needs weekly CBC, AST/ALT/ALK Phos/T Bili/Alb, Chem 7. Please
fax results to Dr. ___.
10. Peridex *NF* (chlorhexidine gluconate) 15 mL PO BID:PRN
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
RX *chlorhexidine gluconate [Peridex] 0.12 % Mouthwash with 15mL
Twice a day Disp #*2 Bottle Refills:*0
11. Miconazole Powder 2% 1 Appl TP BID
around G tube per wound care recs
RX *miconazole nitrate [Anti-Fungal] 2 % Apply to surrounding
wound area Twice a day Disp #*2 Bottle Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: G-TUBE MIGRATION
Secondary: Congenital intestinal pseudoobstruction s/p
intestinal transplant x2, Upper extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to ___ for migration of your G-tube site and
pain around G-tube site. You were seen by the surgery team who
decided to take you to the OR and replace the G Tube as well as
create a stomach osteomy. You had electrolyte abnormalities
which improved with IV fluids. You had fevers and were seen by
infectious disease specialists. We used a few different
antibiotics which you had adverse reactions to. We eventually
treated you for a pnuemonia with Doxycycline (as well as for a
suspected MRSA catheter tip infection). You need to take
Doxycyline for the suspected catheter tip infection until you
see the infectious disease specialist. We do not think you had
an infection of the ICD leads (the imaging study did not suggest
that). You had substantial pain that was controlled with IV
Dilaudid. We weaned you off IV Dilauded as best as we could.
Pain Medicine could not make any specific suggestions in light
of your inability to take pills by mouth.
Of note, we recommended anticoagulation for the upper extremity
DVT. We offered injections and rectal administration of blood
thinners, however, you did not like those options. We discussed
the risk and benefits of this decision.
Transitional Issues
Please follow-up with your appointments as listed.
Please contact ___ for any issues with the IV
medications - ___.
Please continue IV Doxycycline until you see the infectious
disease specialist.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Gabapentin 600 mg PO TID
2. ClonazePAM 2 mg PO BID:PRN Anxiety
3. Claritin-D 24 Hour (loratadine-pseudoephedrine) ___ mg
oral DAILY
4. Mucinex DM (dextromethorphan-guaifenesin) ___ mg oral
Q6H:PRN Congestion
5. Multivitamins 1 TAB PO DAILY
6. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Syncope
Hypertensive Urgency
Secondary:
Generalized Anxiety Disorder
Bipolar Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital after an episode of losing
consciousness (syncope). We performed numerous tests and
determined your syncope is not related to a problem with your
heart. We believe your syncope is likely due to a common
condition known as vasovagal, where your body reacts suddenly to
changes and stressors, causing you to briefly lose
consciousness.
You were provided with a heart monitor and instructed on its
use. This is to be absolutely sure there is not any cause
related to the heart.
Because your blood pressure was high you were started on a new
blood pressure medication.
It was a pleasure taking care of you,
-Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Calcium Carbonate 1500 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Levothyroxine Sodium 300 mcg PO DAILY
6. Acetaminophen 650 mg PO Q4H:PRN fever, pain
7. Carvedilol 12.5 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
10. alpha lipoic acid *NF* 50 mg Oral daily
11. Ascorbic Acid ___ mg PO DAILY
12. Fish Oil (Omega 3) ___ mg PO DAILY
13. garlic *NF* 1,000 mg Oral daily
14. Vitamin D ___ UNIT PO DAILY
15. Testim *NF* (testosterone) 50 mg/5 gram (1 %) Transdermal
daily
16. Vitamin E 100 UNIT PO DAILY
17. Glargine 33 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
18. Clopidogrel 75 mg PO DAILY
19. Heparin 5000 UNIT SC TID
20. Milk of Magnesia 30 ml PO DAILY
21. ertapenem *NF* 1 gram Intravenous 24hrs Reason for Ordering:
per ID
22. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
23. ertapenem *NF* 1 gram Intravenous x1 stat Reason for
Ordering: per ID
24. Potassium Chloride 20 mEq PO BID
25. Ranitidine 150 mg PO DAILY
26. Vancomycin 1000 mg IV Q 12H
27. Furosemide 40 mg PO QPM
28. Furosemide 80 mg PO DAILY
29. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
30. Levothyroxine Sodium 25 mcg PO EVERY OTHER DAY
31. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
32. Amlodipine 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aortic stenosis
Coronary Artery Disease, prior CABG ___
Dyslipidemia
Hypertension
Carotid artery disease, History of Left CEA
Pheripheral vascular disease, s/p Bilateral iliac artery
stenting
Insulin Dependent Diabetes (nephropathy, neuropathy,
retinopathy)
Chronic Kidney Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned-non weightbearing right foot
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg: Left - healing well, no erythema or drainage.
Edema: trace bilat
Followup Instructions:
___ [/INST] </s><s>Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 4
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice per day Disp #*8 Capsule Refills:*0
2. Aspirin 162 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Cilostazol 100 mg PO BID
5. Ciprofloxacin 0.3% Ophth Soln 1 DROP RIGHT EYE BID
6. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye)
BID
7. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE DAILY
8. Lumigan (bimatoprost) 0.01 % OD QHS
9. Metoprolol Tartrate 12.5 mg PO DAILY
10. netarsudil 0.02 % ophthalmic (eye) QHS
11. Pantoprazole 40 mg PO Q24H
12. Tamsulosin 0.4 mg PO QHS
13. ValACYclovir 1000 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to care for you while you were hospitalized.
You were admitted to the hospital due to weakness and increased
urinary frequency. You were found to have a urinary tract
infection. You improved with treatment with IV antibiotics and
are now ready for discharge. Following discharge, you will
require another 4 days of antibiotics. Please complete the
course as prescribed.
Please follow up with Dr. ___ as planned next week.
Take care,
Your BI Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
2. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN agitation
RX *olanzapine 5 mg 1 tablet(s) by mouth twice daily Disp #*10
Tablet Refills:*0
3. OLANZapine (Disintegrating Tablet) 10 mg PO QHS
RX *olanzapine 10 mg 1 tablet(s) by mouth bedtime Disp #*5
Tablet Refills:*0
4. Lorazepam 0.5-1 mg SL Q4H:PRN seizure/agitation
Please note this medication is very sedating for the patient.
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
pain/shortness of breath
7. Acetaminophen 650 mg PR Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Encephalopathy secondary to UTI
Glioblastoma
Dementia
Malnutrition
___
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital for altered mental status
thought to be related to a UTI. You were treated with
antibiotics with some improvement. We are discharging you to
hospice to focus on improving your symptoms.
Take care, and we wish you the best.
Sincerely,
Your oncology team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Allopurinol ___ mg PO DAILY
2. Docusate Sodium (Liquid) 100 mg PO DAILY:PRN constipation
3. Ferrous Sulfate 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Mirtazapine 7.5 mg PO HS
6. Multivitamins W/minerals 1 TAB PO DAILY
7. QUEtiapine Fumarate 12.5 mg PO BID:PRN agitation
8. Senna 1 TAB PO BID
9. Acetaminophen 650 mg PO QHS
10. Finasteride 5 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Cyanocobalamin ___ mcg PO DAILY Duration: 2 Weeks
13. Metoprolol Succinate ___ 25 mg PO HS
Discharge Disposition:
Expired
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Aspiration Pneumonia, Acute on Chronic Kidney
Failure
Secondary Diagnosis: Anemia, Diastolic Congestive Heart Failure,
Vascular Dementia, Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you were found to be more confused and sleepy. You had
imaging of your chest and were found to have a pneumonia which
was treated with antibiotics and improved. You also had an
injury to your kidney which appears to be improving.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
All the best,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Senna 1 TAB PO BID:PRN Constipation
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Acetaminophen 650 mg PO Q6H
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 1 mg/mL ___ Liquid(s) G tube Q3HRS Disp #*3
Bottle Refills:*0
7. OxycoDONE Liquid 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 10 mL G tube Q4HRS Disp #*3 Bottle
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. C1 fracture.
2. C2 fracture.
3. Occipital fracture.
4. Infiltrative lesion occiput, C1, C2.
5. Metastatic disease consistent with squamous cell
carcinoma, tonsillar.
6. Neck pain.
7. Spinal cord stenosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed.
-Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
-Follow up:
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
oAt the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
oWe will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
Activity: Activity: Activity as tolerated
Cervical collar: At all times
___ Goals
Time Frame: 1 week
1 - Indep state ___ spinal precautions
2 - CGA amb 100' c LRAD
3 - Tolerate high level balance test
4 - Indep supine to sit with HOB flat
Treatments Frequency:
Site: Posterior neck
Description: surgical incision
Care: asses SS of infection</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Levothyroxine Sodium 50 mcg PO DAILY
2. Lorazepam 0.5 mg PO HS:PRN insomnia
3. Sertraline 75 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
Continue this medication as prescribed until all of the pills
are gone.
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*20 Tablet Refills:*0
5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Cholangitis with biliary obstruction (choledocolithiasis)
# Pancreatic fullness; MRCP report pending
# Weight loss/malnutrition, chronic loose stool
# Acute GNR acute blood stream infection
# New onset Atrial Fibrillation
Secondary:
# Depression
# Hypothyroidism
# Glaucoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You were hospitalized with a blockage in your bile duct due to
stones. The stones were removed by ERCP procedure. You also had
an infection in your bile ducts which is being treated with
antibiotics. It is very important that you complete the
Ciprofloxacin prescription as prescribed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: Patient left against medical advice and was advised to complete
her prior Flagyl prescription and continue her outpatient meds
noted on admission as prescribed by her physicians.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Patient leaving against medical advice.
Ambulatory
Mental status clear and coherent
Followup Instructions:
___ [/INST] </s><s>You acknowledge that you are leaving against medical advice.
You were informed about an incidental 3mm lung nodule seen on
your CT scan and the need to follow this finding up with your
PCP to make sure that it is not cancerous (your risk is very low
of cancer).
You should not take opiate pain medication as this will worsen
your gastric paresis, and risks intestinal perforation with
concurrent C. difficile infection (which you report).
Please complete your Metronidazole (Flagyl) course which you
were prescribed by another physician. Please follow up with
your PCP in person or at the very least by phone no later than
tomorrow.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Propranolol 20 mg PO BID
RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
3. Calcium Carbonate 1000 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Lactulose 30 mL PO TID
10. LevETIRAcetam 500 mg PO BID
11. Magnesium Oxide 800 mg PO QID
12. Mirtazapine 30 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
14. Ranitidine 150 mg PO DAILY
15. Rifaximin 550 mg PO BID
16. Spironolactone 25 mg PO DAILY
17. Sucralfate 2 gm PO BID
18. Thiamine 100 mg PO DAILY
19. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Hypomagnesemia
Hypokalemia
Hypophosphatemia
Alcohol dependence with withdrawal
History of seizures
Cirrhosis with history of esophageal varices
Elevated LFTs
Neutropenia
Pancytopenia
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
You were hospitalized with signs of alcohol withdrawal. You
were treated with phenobarbital and this has been very helpful
for managing your withdrawal. It is very important to avoid any
further alcohol use. If you feel like you're going to drink
alcohol again, please call your doctor ___. Alcohol use is
causing multiple medical problems including electrolyte
abnormalities, low blood counts, abnormal liver function tests.
Please talk with your social workers as well and consider
outpatient rehabilitation programs if possible.
You were found to have multiple lab abnormalities including
severely low magnesium, potassium and phosphorus. You were
given IV and oral supplements of these and they have improved.
I have recommended that your PCP's office recheck these labs at
your visit on ___ to make sure they do not become too low
again. It is important to stay well hydrated and eat regularly.
Your liver function tests were elevated but an ultrasound showed
no abnormalities (including no obstruction) in your liver or
bile ducts. These tests are all improving, likely due to not
drinking alcohol. I recommend having these rechecked as well.
You have chronically low blood counts, which were very low on
admission. You had a low white blood cell count and especially
concerning, was a low neutrophil count. Fortunately your blood
counts are improved since admission and again likely due to not
drinking alcohol. Please have your blood counts checked again.
If you have any signs of bleeding, it is critical to have your
counts rechecked.
It was a pleasure to take care of you here at ___ and we wish
you good health and recovery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. BuPROPion (Sustained Release) 100 mg PO QAM
2. Sertraline 50 mg PO DAILY
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Do not drive or combine with alcohol.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
6. Famotidine 20 mg PO BID
7. Acetaminophen 650 mg PO Q8H:PRN pain
8. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
.
You were admitted to the gynecologic oncology service after
presenting with a small bowel obstruction. While you were in the
hospital we stopped your diet entirely to give your bowels rest
and controlled your abdominal pain with pain medications. We
then gradually advanced your diet. You have recovered well, and
the team feels that you are safe to be discharged home. Please
continue to self-regulate your diet and follow the
recommendations provided to you by Nutrition for a low residue
diet.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acyclovir 400 mg PO Q12H
2. amLODIPine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Spironolactone 25 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- Dexamethasone 10 mg PO ASDIR This medication was
held. Do not restart Dexamethasone until discussing with Dr.
___
11. HELD- Pomalyst (pomalidomide) 2 mg oral DAILY This
medication was held. Do not restart Pomalyst until discussing
with Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
#Meningoencephalitis NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
Thank you for coming to ___ for your care. Please read the
following directions carefully:
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had fevers and
confusion while you were at home
- We were concerned you had an infection that involves your
brain and spinal cord.
WHAT WAS DONE FOR ME WHILE I WAS HERE?
- You had several tests including a spinal tap and an MRI. These
unfortunately did not show exactly what bacteria or virus could
be causing your symptoms
- We gave you a course of antibiotics through an IV to treat
several possible causes of these kinds of infections
WHAT DO I NEED TO DO AFTER I LEAVE THE HOSPITAL?
- The medications you were taking before you came to the
hospital have not been changed. They are listed below as well
- Please keep your appointments as listed below
- If you develop new fevers, confusion, or any other concerning
symptoms, please seek urgent medical attention
We wish you the best with your health!
- Your ___ care team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. AcetaZOLamide 500 mg PO Q12H
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron HCl 8 mg 1 tablet(s) by mouth q8hrs Disp #*9
Tablet Refills:*0
4. ketorolac 10 mg oral q6hrs PRN headache
RX *ketorolac 10 mg 1 tablet(s) by mouth q6hrs Disp #*8 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. chiari malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear. Ms ___,
You were admitted for evaluation of your headache. It was
different from your previous headaches associated with
pseudotumor, was bad throughout the day (regardless of
cough/laugh) and was associated with neck pain, upper back
numbness, and right more than left hand numbness. After thorough
evaluation, we feel that your headache may now be primarily
secondary to you Chiari malformation. We performed a cervical
spine MRI during your stay to make sure your symptoms were not
from spinal compression from any other etiology - this exam was
remarkable only for your low lying cerebellar tonsils consistent
with Chiari malformation. You will follow up with Neurosurgery
for further Chiari evaluation, MRI CSF CINE flow study, and for
discussion of neurosurgical evaluation.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*9 Tablet Refills:*0
4. Alendronate Sodium 35 mg PO WEEKLY
5. amLODIPine 5 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 2 Days
Continue through ___ then stop as previously prescribed
7. ___ mg/mL ophthalmic BID
8. HydrALAZINE 50 mg PO BID
9. LaMIVudine 50 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Mycophenolate Mofetil 500 mg PO BID
12. Sodium Bicarbonate 650 mg PO BID
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Tacrolimus 2 mg PO Q12H
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
subdural hematoma
atrial fibrillation
h/o kidney transplant
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions
Brain Hemorrhage without Surgery
Activity
路 We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your ___ appointment.
路 You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
路 No driving while taking any narcotic or sedating medication.
路 If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
路 No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
路 ***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You should hold Eliquis until follow up with neurosurgery in 1
month with a repeat head CT.
路 ***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication for a through ___, then stop. It is important that
you take this medication consistently and on time.
路 You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
路 You may have difficulty paying attention, concentrating, and
remembering new information.
路 Emotional and/or behavioral difficulties are common.
路 Feeling more tired, restlessness, irritability, and mood
swings are also common.
路 Constipation is common. Be sure to drink plenty of fluids and
eat a ___ diet. If you are taking narcotics (prescription
pain medications), try an ___ stool softener.
Headaches:
路 Headache is one of the most common symptom after a brain
bleed.
路 Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
路 Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
路 There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
路 Severe pain, swelling, redness or drainage from the incision
site.
路 Fever greater than 101.5 degrees Fahrenheit
路 Nausea and/or vomiting
路 Extreme sleepiness and not being able to stay awake
路 Severe headaches not relieved by pain relievers
路 Seizures
路 Any new problems with your vision or ability to speak
路 Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
路 Sudden numbness or weakness in the face, arm, or leg
路 Sudden confusion or trouble speaking or understanding
路 Sudden trouble walking, dizziness, or loss of balance or
coordination
路 Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 5 mg PO BID
hold for SBP < 105
2. Clonazepam ___ mg PO BID:PRN anxiety
hold pls if sedated or RR < 10
RX *clonazepam 1 mg ___ tablet(s) by mouth twice per day Disp
#*5 Tablet Refills:*0
3. Kaletra 2 TAB PO BID
4. Truvada 1 TAB PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipat
8. CefePIME 1 g IV Q12H
continue through ___
9. Docusate Sodium 100 mg PO BID
10. Heparin 7500 UNIT SC TID
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Methadone 90 mg PO DAILY
hold for sedation, RR<10
RX *methadone 10 mg 9 tabs by mouth daily Disp #*18 Tablet
Refills:*0
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
continue through ___
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
HOLD for sedation, RR<12, confusion
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*15 Tablet Refills:*0
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 1 TAB PO BID:PRN constipation
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
19. Beclomethasone Dipro. AQ (Nasal) *NF* 42 mcg Other TID
20. Loratadine *NF* 10 mg Oral daily
21. Vitamin D 1000 UNIT PO DAILY
22. Outpatient Lab Work
Diagnosis: empyema
CBC with differential (weekly) (x)
Chem 7 (weekly) (x)
BUN/Cr (weekly) (x)
AST/ALT (weekly) (x)
Alk Phos (weekly) (x)
Total bili (weekly) (x)
ESR/CRP (weekly) (x)
All laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___
___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Empyema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted with pneumonia and infected fluid in your
lung. You had this drained with a chest tube and you were
started on antibiotics. Based on the results of type of
bacteria, you will require 4 weeks of intravenous antibiotics.
You will need to follow up with infectious disease doctors to
make sure you continue to have improvement.
You were found to be slightly weak from your long
hospitalization. You were discharged to rehab so you could get
your antibiotics and improve your strength.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Furosemide 20 mg PO BID
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Midodrine 10 mg PO BID
Take at 8 AM and 2PM
RX *midodrine 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Sodium Chloride Nasal ___ SPRY NU QID:PRN epistaxis, nasal
dryness
RX *sodium chloride [Saline Nasal] 0.65 % ___ spray intra nasal
BID:PRN Disp #*1 Bottle Refills:*0
8. Spironolactone 50 mg PO BID
RX *spironolactone 50 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
10.Outpatient Lab Work
Please check CBC, Chem10, LFTs on ___ and fax to 1)
___ Attn. Dr. ___ 2) ___ Attn. Dr.
___
11.Durable Medical Equipment
Rolling Walker
orthostatic hypotension. ICD 10: I95.1.
Duration: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: decompensated cirrhosis, alcohol-induced
Secondary diagnosis: chronic systolic heart failure, orthostatic
hypotension, protein energy malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
================================
WHY DID YOU COME TO THE HOSPITAL?
================================
- For evaluation of swelling in your legs and abdomen
=====================================
WHAT WAS DONE FOR YOU DURING YOUR STAY?
=====================================
- You were diagnosed with cirrhosis of the liver, which in your
case is related to alcohol use. This led to the fluid build up
in your belly.
- It was found that your heart does not pump as strong as it
should (called heart failure), which also led to the fluid
building up.
- The extra fluid was removed by giving you medications to
increase urination ("water pills"/"diuretics") and by draining
the fluid directly from your belly with a needle
("paracentesis") twice
- A scope was done of the tube leading to your gut (esophagus)
using a camera ("EGD") and did NOT see any large veins
("varices") that were at risk of bleeding.
- A nutritionist developed a high protein-low salt meal plan to
help rebuild muscle mass and keep the fluid off.
==============================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==============================================
- Stop drinking alcohol completely, even 1 drink is too many.
- Take all the medications as prescribed (see below)
- Follow up on ___ with your primary care physician's
office
- Follow up in liver clinic with Dr. ___ as below
- Follow up in cardiology clinic (see below)
- Weigh yourself everyday and let you primary doctor know if
your weight goes up by more than 3 pounds in 2 days.
- Make sure to drink an Ensure with breakfast, lunch, and dinner
everyday.
- Eat no more than 2g of salt every day
- Use the rolling walker to get around and if you ever feel
dizzy or lightheaded, seek medical attention immediately
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours).
Disp:*14 syringe* Refills:*0*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3h as needed for
Pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Ankle trimalleolar fracture dislocation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. Always remove your bivalve cast when taking
a shower, do not get it wet. You may continue dry sterile
dressings with ABD pad to the wound, and wrap with kerlix or ace
wrap. No baths or swimming for at least 4 weeks. Any stitches
or staples that need to be removed will be taken out at your
2-week follow up appointment. No dressing is needed if wound
continued to be non-draining.
******WEIGHT-BEARING*******
Right lower extremity: Non-weight bearing in splint
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with ___ in ___ days
post-operation for evaluation and staple/suture removal. Call
___ to schedule appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization at ___. You
were admitted after becoming ill at your home. On arrival to
the hospital you were found to be very dehydrated with a very
high blood sugar. Because of this you were initially admitted
to the medical intensive care unit. You improved and were moved
to regular medical floor. To continue to regain your strength
you will now be discharged to a rehab facility. We wish you
luck in your continued recovery!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ursodiol 500 mg PO BID
RX *ursodiol 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Cyclobenzaprine 5 mg PO QHS PRN back pain
4. Glargine 50 Units Dinner
novolog 12 Units Breakfast
novolog 12 Units Lunch
novolog 12 Units DinnerMax Dose Override Reason: per ___ recs
RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL 0.5 (One
half) ml subcutaneously nightly Disp #*1 Vial Refills:*0
RX *insulin admin supplies [InPen (for Novolog)] AS DIR 12
Units before breakfast; 12 Units before lunch; 12 Units before
dinner Disp #*1 Syringe Refills:*0
5. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
6. Amitriptyline 100 mg PO QHS
7. Citalopram 20 mg PO DAILY
8. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary
Cholelithiasis
#Secondary:
Cirrhosis, unclear etiology
Diabetes mellitus type II, insulin dependent
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why you were admitted to the hospital:
- You were having abdominal pain, particularly with eating
- You were diagnosed with gallstones, which are likely causing
your pain
What happened while you were here:
- Surgery was deferred due to a high risk of complications
- You were treated medically and your pain slowly improved
- Additionally, work up showed that you have cirrhosis, which is
scarring of the liver
- Several tests were sent to find out the cause of the scarring,
many of which were still pending at discharge
What you should do once you return home:
- Please continue taking your medications as prescribed
- Please follow up with the appointments outlined below.
Specifically, you should see your primary care provider, ___ liver
doctor, and the diabetes doctor
- If you do not wish to attend the ___ appointment, please
call your endocrinologist to schedule an appointment within ___
weeks
- You should decrease the dose of the cyclobenzaprine and
sumatriptan given the new diagnosis of cirrhosis
We wish you the best.
Sincerely,
Your ___ Care team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Apixaban 5 mg PO BID
2. HYDROcodone-acetaminophen 7.5-300 mg oral PRN Pain
3. Metoprolol Succinate XL 25 mg PO BID
4. Flecainide Acetate 50 mg PO Q12H
5. Vitamin D ___ UNIT PO WEEKLY
6. Zolpidem Tartrate 5 mg PO QHS:PRN sleep aid
Discharge Disposition:
Home
Discharge Diagnosis:
Thyroiditis
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ for a recurrence of atrial
fibrillation and hyperthyroidism related to thyroiditis as shown
by thyroid scan.
Continue all of your medications with the following changes:
- Start Apixaban (Eliquis) 5mg twice a day. This medication is
a blood thinner that prevents blood clots from forming in your
heart due to atrial fibrillation.
- Stop aspirin and levothyroxine.
- Increase Metoprolol Succinate to 25mg twice a day. This is to
keep your heart rate under control.
You did not have a cardioversion to get you back in a normal
heart rhythm because the Electrophysiology doctors ___ your
___ function back to normal prior to attempting a
cardioversion.
If you have any urgent questions that are related to your
recovery from your medical issues or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the ___ HeartLine at
___ to speak to a cardiologist or cardiac nurse
practitioner.
It has been a pleasure to have participated in your care and we
wish you the best with your health!
Your ___ Cardiac Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. OLANZapine 5 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. Aspirin 81 mg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
7. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID
8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Fluoxetine 40 mg PO DAILY
12. LaMOTrigine 100 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. Outpatient Lab Work
Check INR and Chem 10 on ___.
ICD-9: 428.0 Congestive heart failure
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES:
Healthcare Associated Pneumonia
Altered mental status
SECONDARY DIAGNOSES:
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
It was a pleasure taking care of you at the ___
___ ___. You were admitted for pneumonia and
because you were not behaving as your usual self. You were
treated with antibiotics and your pneumonia resolved. You
received a lot of fluids while in the hospital which caused
fluid build up in and around your lungs. We treated this with
medication which made you urinate all the excess fluid.
Please continue to take all your medication as prescribed.
Weigh yourself every morning, if weight goes up more than 3 lbs
please increase your lasix from 40mg once a day to 40mg every 12
hours (twice a day).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for chest pain. A study of the blood vessels that
supply your heart (cardiac catheterization) showed stable
blockages of a few vessels, and no intervention was felt to be
necessary. Though it is clear that you did not suffer a heart
attack, it is less clear what might have caused your chest pain.
However, if you have severe pain again, you should immediately
return to the emergency department for evaluation.
No changes were made to your medications.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive or drink alcohol while taking this
2. Insulin Pump SC (Self Administering Medication)
Basal Rates:
Midnight - 4A: 1.75 Units/Hr
4A - 10A: 1.5 Units/Hr
10A - midnight: 1.3 Units/Hr
Meal Bolus Rates:
Breakfast = 1:5
Lunch = 1:5
Dinner = 1:5
Snacks = 1:5
MD acknowledges patient competent
MD has ordered ___ consult
MD has completed competency
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with right lower quadrant pain
and were found to have acute appendicitis. You were taken to the
operating room and had your appendix removed laparoscopically.
You tolerated the procedure well and are now being discharged
home to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Labetalol 300 mg PO TID
RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
6. Mirtazapine 15 mg PO HS
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Simvastatin 40 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
10. fenofibrate 54 mg oral daily
11. FiberCon (calcium polycarbophil) 625 mg oral BID
12. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you during your admission to ___
___. As you know, you came in with
chest pain. Your EKG and blood tests did not show evidence of a
heart attack and your pain improved.
During your stay, your blood pressure was very high, and we
increased your labetolol to three times per day. We did not make
any other changes to your medications. Please call your doctor
right away if you feel lightheaded or dizzy, or if you have
chest pain or a racing heart beat again.
Please weigh yourself every morning and call your doctor if
weight goes up more than 3 lbs. Once again, it was a pleasure
caring for you and we wish you the best,
Sincerely,
Your Medical Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO QHS
2. Gabapentin 300 mg PO QHS
3. Omeprazole 20 mg PO DAILY
4. Oxcarbazepine 1200 mg PO QAM
5. glimepiride 2 mg ORAL BID
6. Invokana (canagliflozin) 300 mg oral DAILY
7. liraglutide 1.8 mg subcutaneous DAILY
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO LUNCH
11. Meclizine 12.5 mg PO TID
RX *meclizine 12.5 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
12. Outpatient Physical Therapy
Vestibular Outpatient Rehab for Left Peripheral Hypofunction
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Benign Positional Paroxysmal Vertigo
# Viral Gastroenteritis / Abdominal Pain / Nausea
# Type 2 Diabetes with neurologic complications
# Bipolar disorder
# Hyperlipidemia
# GERD
# Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure caring for you at ___. You were admitted
with nausea and vomiting. You underwent testing that did not
show signs of a serious infection. Your symptoms improved--you
most likely had a "stomach bug" (viral gastroenteritis).
While you were here, you were also dizzy. This is likely the
result of a condition called "benign paroxysmal positional
vertigo". This may be a result of your recent viral infection.
It should resolve over time--in the meantime, we recommended
using a medication called meclizine to treat your symptoms. You
were seen by a physical therapist who recommended that you
continue to see a physical therapist to help you with these
symptoms.
You have improved and are now ready for discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Device
Type of equipment: Rolling walker
Reason: gait training
Length of need: Lifetime
Diagnosis: post-viral syndrome
prognosis: good
2. Lorazepam 0.5 mg PO BID:PRN anxiety
3. Pantoprazole 40 mg PO Q12H
4. Rosuvastatin Calcium 10 mg PO QOD
5. ___ (cranberry extract) 3000 mg oral daily
6. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40 mg-unit-mcg
oral BID
7. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recent viral gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You were admitted with difficulty walking. You were seen by
physical therapy and they recommended a rolling walker and
continued physical therapy at home.
MRI of the brain showed several very tiny "specks" that the
radiologist thought could be old tiny strokes, but nothing new
or "acute" that would explain your recent symptoms.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*0
3. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
5. Warfarin 7.5 mg PO DAILY16
RX *warfarin 2.5 mg 3 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*0
6. Aspirin 81 mg PO DAILY
7. Calcium Carbonate 1250 mg PO TID W/MEALS
8. Cyanocobalamin 1000 mcg IM/SC QMONTH
9. Docusate Sodium 100 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13.Outpatient Lab Work
Draw labs on ___
Indication: Heart failure (ICD-9-CM 428.00)
Labs to draw: Chem-10 panel
Fax results to: Dr. ___ (F: ___ and Dr. ___
___ (F: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acutely Decompensated Heart Failure with preserved Ejection
Fraction
Atrial fibrillation
Acute on chronic kidney disease
SECONDARY DIAGNOSIS
Coronary artery disease
Diabetes
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to be part of your care at ___.
You were admitted to the hospital because you were having
difficulty breathing and were having leg swelling, which were
concerning for a heart failure exacerbation. This heart failure
exacerbation was likely exacerbated by an episode of atrial
fibrillation.
You were treated with diuretics to help get rid of the extra
fluid that you had accumulated as a result of your heart failure
and with a medicine to help your heart beat more efficiently.
In the hospital you received a cardioversion to help return your
heart back to a normal rhythm. Your home beta-blocker
(carvedilol) was stopped. You were not re-started on a
beta-blocker because your blood pressure was low. Your heart
remained in a normal rhythm for most of your stay, however at
the end it converted back to an irregular rhythm. You underwent
a second cardioversion on ___.
Your diuretic Lasix was switched to torsemide 40 mg, which you
should take twice a day.
If you experience any worsening difficulty breathing or
accumulation of swelling in your legs, please contact your
doctor.
Please monitor your INR daily and call the result in to your
PCP, ___ (___).
We wish you the best,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Calcium Carbonate 500 mg PO QID:PRN indigestion
2. Famotidine 20 mg PO BID
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
4. Lisinopril 2.5 mg PO DAILY
5. macitentan 10 mg oral daily
6. Magnesium Oxide 400 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. sildenafil 20 mg oral TID
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 2.5 mg PO 4X/WEEK (___)
11. Torsemide 20 mg PO DAILY
RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Warfarin 2.5 mg PO DAILY16
13. Acetaminophen 325 mg PO Q6H:PRN pain
14. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Heart failure exacerbation
Secondary:
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Atrial fibrillation, anticoagulated for at least last ___ years
Hypertension
Hyperlipidemia
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with assist.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It has been a pleasure taking part in your care during your
hospitalization. You were admitted to ___
___ for an exacerbation of heart failure, with weight
gain and swelling despite an increase of your dose of lasix.
Please continue to take your home medications. Please follow up
with the appointments as described below. Weigh yourself every
morning, call your doctor if your weight goes up more than 3 lbs
in one day or more than 5 lbs in one week.
Again, it has been a pleasure taking part in your care and we
wish you the best.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain-Mild/Fever >100
2. Bacitracin Ointment 1 Appl TP QID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Phenazopyridine 100 mg PO Q8H:PRN dysuria/urgency Duration:
3 Days
RX *phenazopyridine 100 mg ONE tablet(s) by mouth Q8hrs Disp #*9
Tablet Refills:*0
5. Senna 17.2 mg PO QHS
6. Acyclovir 400 mg PO 5X/D ___ flare
7. Finasteride 5 mg PO DAILY
8. Losartan Potassium 50 mg PO QHS
9. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hematuria, gross
retention, clot urinary
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>These steps can help you recover after your procedure.
聲DO drink plenty of water to flush out the bladder.
聲DO avoid straining during a bowel movement. Eat
fiber-containing foods and avoid foods that can cause
constipation. Ask your doctor if you should take a laxative if
you do become constipated.
聲Don't take blood-thinning medications until your doctor says
it's OK.
聲Don't do any strenuous activity, such as heavy lifting, for
four to six weeks or until your doctor says it's OK.
聲Don't have sex. You'll likely be able to resume sexual
activity in about four to six weeks.
聲Don't drive until your doctor says it's OK. ___, you can
drive once your catheter is removed and you're no longer taking
prescription pain medications.
聲You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve. You may
have clear or yellow urine that periodically turns pink/red
throughout the healing process. Generally, the discoloration of
the urine is 聯OK聰 unless it transitions from ___,
___ Aid to a very dark, thick or 聯like tomato juice聰
color
聲Resume your pre-admission/home medications EXCEPT as noted.
You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care team.
聲Unless otherwise advised, blood thinning medications like
ASPIRIN should be held until the urine has been clear/yellow for
at least three days. Your medication reconciliation will note
if you may resume aspirin or prescription blood thinners (like
Coumadin (warfarin), Xarelto, Lovenox, etc.)
聲-an ointment like bacitracin/Neosporin or "triple antibiotic"
ointment is recommended for comfort at urethral meatus where the
foley catheter inserts. Apply the ointment for comfort ___ x
daily if needed.
聲If needed, you will be prescribed an antibiotic to continue
after discharge or save until your Foley catheter is removed
(called a 聯trial of void聰 or 聯void trial聰).
聲You may be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
聲Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and it is available
over-the-counter
聲AVOID STRAINING for bowel movements as this may stir up
bleeding. Avoid constipating foods for ___ weeks, and drink
plenty of fluids to keep hydrated
聲No vigorous physical activity or sports for 4 weeks or until
otherwise advised
聲Do not lift anything heavier than a phone book (10 pounds) or
participate in high intensity physical activity (which includes
intercourse) for a minimum of four weeks or until you are
cleared by your Urologist in follow-up
聲Acetaminophen (Tylenol) should be your first-line pain
medication. A narcotic pain medication may also be prescribed
for breakthrough or moderate pain.
聲The maximum daily Tylenol/Acetaminophen dose is 3 grams from
ALL sources.
聲Do not drive or drink alcohol while taking narcotics and do
not operate dangerous machinery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Clindamycin 300 mg PO Q8H
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Metoprolol Tartrate 75 mg PO BID
9. Montelukast 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Allopurinol ___ mg PO DAILY
14. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalemia and ___ of multifactorial origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure treating you at the ___
___. You were admitted because of your high potassium
level and abnormal kidney function lab markers. In the emergency
department, you were given fluids and admitted overnight for
further monitoring of your electrolyte balance. In the morning,
your kidney function and potassium level (along with other
electrolytes) improved. We continued your fluids while holding
your lisinopril. Afternoon labs returned with continued
improvement and you were discharged to ___ with with your
PCP.
***PLEASE USE LAB SCRIPT TO HAVE BLOOD DRAWN ___, LABS SHOULD
BE FAXED TO ___ ___ ___
STOP:
-- Lisinopril until you see your PCP or ___
HOLD:
-- Warfarin, while taking Lovenox per Dr. ___ your ___
Fissure Procedure
Best of Health,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q6H
2. Ibuprofen 600 mg PO Q8H:PRN pain
Please take with water and food
Discharge Disposition:
Home
Discharge Diagnosis:
-Hypercalcemia
-Primary hyperparathyroidism
Discharge Condition:
Alert and oriented x3, cohesive
Ambulating per baseline
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were admitted to the hospital because you were found to
have a high calcium level in your blood.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You got IV fluids to help lower the calcium in your blood. When
you were not on IV fluids, the calcium level went back up.
-You were seen by the endocrinology team, who believe the high
calcium level is due to an issue with your parathyroid gland
(the gland that controls calcium levels in your blood).
-You were seen by the endocrine surgery team, who recommended
surgery to remove the parathyroid glands.
You were taken to the OR on ___ for a right upper
parathyroidectomy with Dr. ___. You tolerated this
procedure well and recovered uneventfully. You were discharged
home once you were eating, on oral medications, walking, and
completing daily activities per normal.
MEDICATIONS:
For pain medication you may take acetaminophen (Tylenol) or
ibuprofen (Motrin). You requested a recovery without opioid
analgesics and achieved appropriate pain control without them
postoperatively. You may restart all your usual home
medications.
SYMPTOMS OF LOW CALCIUM:
If you develop tingling or numbness around your mouth,
fingertips or legs, this may be a sign of a low calcium and you
should call our office. If you develop severe symptoms, please
go to emergency room.
WOUND CARE:
You may shower normally starting tonight. Allow warm soapy water
to run over the wound, rinse and pat dry gently. There is no
need to keep a dressing over the wound. Do not apply creams or
ointments. Do not submerge the wound in a swimming pool or bath
until cleared at your follow up visit. Do not pull off the steri
strip tapes--these will fall off by themselves over the next ___
weeks.
DIET:
You may resume your regular home diet without restriction. You
should stick to foods that do not upset your stomach. You
may need to start with small meals first and may not feel very
hungry at first. This will improve over time. You may supplement
your diet with protein shakes as needed if you do not feel you
are taking in enough nutrition.
ACTIVITY:
You may resume all of your normal home activities, except for
straining or lifting heavy weight. We recommend you resume
walking, exercise, bathing, per your normal regimen.
WARNING SIGNS:
You should contact our clinic or return to the ED immediately if
you experience any of the following signs or symptoms:
Fever above 101.5
Worsening pain
Worsening GI upset, nausea/vomiting, diarrhea
Change in the appearance of your incision, or redness, swelling,
or change in drainage from your incision
Any other symptoms that concern you
You can contact our clinic at any time with questions or
concerns. You should be seen in our clinic for follow up
following your discharge from the hospital.
Best wishes,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis: Large left MCA stroke with hemorrhagic
conversion
Cause of death: Cardiopulmonary arrest
Discharge Condition:
Pt expired on ___ at 9:59pm
Followup Instructions:
___ [/INST] </s><s>To Whom It ___ Concern,
Mrs. ___ was hospitalized due to symptoms of right sided
weakness and difficulty with speech resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
After family meeting on ___ at 2pm, decision was made to
employ comfort measures only and further intervention was
withheld. Patient passed peacefully on ___ at 9PM, with son
at bedside.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO BID gastroenteritis
2. MetroNIDAZOLE 500 mg PO TID
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Mycophenolate Mofetil 1500 mg PO BID
9. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
Gastroenteritis
Acute kidney injury
Hypovolemic hyponatremia
Hypotension
Bright red blood per rectum
SECONDARY DIAGNSES
Mixed connective tissue disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having diarrhea, vomiting,
and your blood pressure was low
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were diagnosed with gastroenteritis, a problem caused by a
bacteria or virus
- You were started on antibiotics for possible bacteria and
given IV fluids
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand surgery. It is normal to
feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweight bearing right upper extremity, OK for finger range
of motion as taught by the occupational therapist
MEDICATIONS
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 121.5 daily for 4 weeks
WOUND CARE:
- Dressing should remain on at all times. Do not remove. Do not
get wet. You may shower. No baths or swimming for at least 4
weeks.
- Splint must be left on until follow up appointment unless
otherwise instructed
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
-Please follow up with Dr. ___ in the Hand Surgery Clinic
for post-operative evaluation. You have an appointment scheduled
for ___ at 11AM in ___.
___
___
-Please follow up with your primary care doctor regarding this
admission within ___ weeks for any new medications/refills.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Nystatin Cream 1 Appl TP BID Duration: 14 Days
11. Acetaminophen 650 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Acute toxic metabolic encephalopathy
L1 spinal compression fracture with retropulsion
Secondary:
Hypertension
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___
because you fell and fractured your spine. You had an MRI of
your spine that showed a compression fracture of your spine but
did not show any acute compression of your spinal cord. You were
seen by the Orthopedic Spine team, who did not think you needed
surgery. While you were here you got confused, which we think
was caused by pain medications that you took. We also found that
you had low vitamin B12, so we started you on supplementation
that you should continue to take at home. Before you left you
were fitted with a brace for your back that you should use when
you are up walking. You will have a follow-up appointment with
your primary care doctor (___) and the Orthopedic Spine
clinic. It was a pleasure participating in your care - we wish
you all the best.
Sincerely,
Your ___ Medicine Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Rheumatoid Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital for pain in your body, mostly
in your ribs. We tried to treat your pain with pills and a pain
patch but you did not wish to take any pain medications. Our
physical therapists worked with you and felt you would benefit
from rehab. We also had our psychiatrists see you to discuss
your mood but you declined further treatment.
Please follow-up with your PCP after you leave rehab. We made
an appointment for you to see ENT to discuss your ear pain as
below.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H
3. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*60
Tablet Refills:*0
7. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip periprosthetic fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Instructions After Orthopedic Surgery
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
day.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take lovenox for two weeks to help prevent the
formation of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
- You can get the wound wet/take a shower starting 3 days after
surgery. Let water run over the incision and do not vigorously
scrub the surgical site. Pat the area dry after showering.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow
up appointment. No dressing is needed if your wound is
non-draining.
- You may put an ice pack on your surgical site, but do not put
the ice pack directly on your skin (place a towel between your
skin and the ice pack), and do not leave it in place for more
than 20 minutes at a time.
Activity
- Your weight-bearing restrictions are: touch down weight
bearing in the right lower extremity
Physical Therapy:
TDWB LLE
ROMAT
Walker when upright
Treatments Frequency:
Daily dressing changes until wound without drainage.
Then, leave open to air.
Stitches/staples to be removed at scheduled follow up in 2 weeks</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Chlorthalidone 25 mg PO DAILY
2. Morphine SR (MS ___ 30 mg PO DAILY 6PM restless leg
syndrome
3. OxycoDONE (Immediate Release) 10 mg PO BEDTIME breakthrough
pain
4. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: idiopathic headache, diplopia
Secondary: hypertension, pulmonary embolisms on coumadin,
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted for symptoms of headache and double vision.
Your imaging results (CT of the head, and MRI of the brain) did
not show any acute pathology to explain your headache. Your
neurological exam is relatively benign, but we recommend close
follow up with our neuro-ophthamologists (Dr. ___ and
neurology clinics (Drs. ___.
Please call either office (phone numbers below) if you have any
change or worsening of your symptoms.
Please continue to take your anti-hypertensive medication
(Chlorthalidone) and warfarin as directed. You have scheduled
follow up in the ___ clinic on ___.
It was a pleasure caring for you during this hospitalization.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
4. Montelukast Sodium 10 mg PO DAILY
5. Guaifenesin ER 600 mg PO Q12H
6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
7. Tiotropium Bromide 1 CAP IH DAILY
8. CefePIME 2 g IV Q12H
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
with spacer
10. Vancomycin 1000 mg IV Q 12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Multilobar Pneumonia
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure taking care of you at ___
___.
You were admitted to the hospital for shortness of breath and
cough. A chest CT was obtained which suggested a worsening
pneumonia. You were treated with IV antibiotics and nebulizers.
Your oxygen saturations were monitored. The pulmonology team was
consulted and recommended that you be discharged on IV
antibiotics, and that you start taking the medication
fluticasone. Your serum creatinine (a measure of kidney
function) also rose during this admission. This was monitored
and remained stable at the time of discharge.
You were also started on Flomax (also known as Tamsulosin) for
your prostate. Please arrange for follow-up appointment with
Urology as you had previously planned. Let your primary care
physician know if you start to experience dizziness or
lightheadedness while on this medication.
Please attend all of your follow-up appointments. Given your
infection, you will go home on IV antibiotics. You should also
start taking fluticasone with a spacer. Please continue all of
your other medications. Please follow up with your primary care
doctor regarding your kidney function.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>you have facial skin infection
you are leaving against medical advice after the risks were
explained to you. you can lose your vision and cause severe
problems
please seek medical attention if you develop worsened symptoms
of redness, pain, headache, neck stiffness, visual changes</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. HYDROmorphone (Dilaudid) ___ mg PO Q4H
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4
hours as needed Disp #*20 Tablet Refills:*0
2. Gabapentin 1200 mg PO TID
RX *gabapentin 600 mg 2 capsule(s) by mouth three times a day
Disp #*45 Tablet Refills:*0
3. Glargine 40 Units Dinner
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Acetaminophen 1000 mg PO Q8H
5. amLODIPine 5 mg PO DAILY
6. Citalopram 30 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Prazosin 5 mg PO BID
10. Prazosin 2 mg PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why did you come to the hospital?
- Because you were having abdominal pain
What happened while you were in the hospital?
- You were found to have acute pancreatitis, for which you
received iv fluids and pain medication
- You were found to be in alcohol withdrawal and required
several doses of phenobarbital before you improved
- You were also found to have alcoholic hepatitis which
improved.
- Your diabetes was also noted to be poorly controlled and your
insulin regimen was titrated in the hospital. Please follow up
with your doctor for any changes.
- You were seen by our social worker who tried to offered
resources to help you maintain sobriety.
What should you do after you leave the hospital?
-REGARDING YOUR PAIN MEDICATION:
Please take dilaudid 4 mg every 4 hours for the rest of today.
Then tomorrow, take 2 mg every 4 hours.
Then on ___, take 2 mg every 6 hours.
Then on ___, take 2 mg every 8 hours.
Then on ___, take 2 mg every 12 hours and go for your
suboxone appointment.
- Please continue to work on staying sober! You know how
important it is, and we believe that you can be successful this
time.
- Follow up with your primary care doctor about your pain,
suboxone management and your diabetes
- Please schedule an appointment with our Liver clinic to follow
up on your alcoholic hepatitis and Hepatitis C
We wish you the best!
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO BID Duration: 7 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*14 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Terminal Ileitis
SECONDARY DIAGNOSIS
======================
Peptic Ulcer Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
======================================
- You were having abdominal pain and had a CT scan that showed a
bad infection.
WHAT HAPPENED IN THE HOSPITAL?
===================================
- You were started on antibiotics.
- You were seen by the gastroenterologists who recommended that
you continue antibiotics and follow up with them as an
outpatient.
WHAT SHOULD I DO WHEN I GO HOME?
=================================
- You should continue your antibiotics.
- You should be receiving a call early this week to schedule a
colonoscopy.
- Please call your PCP, ___, to schedule follow up in ___
weeks.
Take care,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen 160 mg/5 mL (5 mL) 15 ml by mouth every six
(6) hours Disp #*300 Milliliter Refills:*0
2. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
Do not drive or operate other machinery while using
RX *oxycodone 5 mg/5 mL ___ ml by mouth every four (4) hours
Refills:*0
3. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
RX *ibuprofen 100 mg/5 mL 30 ml by mouth every six (6) hours
Refills:*0
4. Sodium Chloride Nasal ___ SPRY NU QID:PRN nose dryness
RX *sodium chloride [Ocean Nasal] 0.65 % ___ spray Both nostrils
four times a day Disp #*50 Spray Refills:*0
5. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Swich and spit twice a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral LeFort I fractures, right LeFort II fracture, and left
LeFort III fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were seen following a fall after a bicycle ride. You
sustained multiple facial fractures for which you were taken to
the operating room with the Oral Maxillo-Facial Surgery service.
You tolerated your procedure and post-operative course well,
your packing was removed prior to discharge, and you are now
both voiding reliably and taking in enough liquids for
discharge.
You can have a full liquid diet as you had in the hospital.
Make sure you are taking in plenty of calories and protein; we
recommend taking nutritional supplements like "Ensure" three
times daily with meals to help make sure you are taking in
enough nutrition.
You may resume your regular level of activities but you must not
drive nor operate any other form of machinery while under the
influence of narcotic pain medicine like oxycodone. Do not take
more pain medicine than needed.
Take Keflex (cephalexin), an antibiotic, four times daily for 1
week as prescribed. Please resume all other prescribed
medicines you were taking at home before your accident. Take
pain medicine as needed but do not take more than you need and
NEVER operate a vehicle or other machinery while using narcotic
pain medicine. Use your prescription mouth rinse twice daily.
Use nasal spray as needed.
Please follow up in clinic with OMFS and also with occuloplastic
surgery as described below. You do not need to follow up with
the ___ clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lactulose 20 mL PO TID
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Rifaximin 550 mg PO BID
6. Tamsulosin 0.4 mg PO HS
7. TraZODone 12.5 mg PO HS:PRN insomnia
8. Ciprofloxacin HCl 500 mg PO Q12H
to continue through end of ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*7 Tablet Refills:*0
9. Bisacodyl 10 mg PR HS:PRN constipation
10. Calcium Carbonate 500 mg PO DAILY
avoid giving at same time as ciprofloxacin.
11. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID:PRN
face rash
12. FoLIC Acid 1 mg PO DAILY
13. Metoclopramide 10 mg PO QIDACHS
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
avoid giving at same time as ciprofloxacin.
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
16. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting
17. Simethicone 160 mg PO TID:PRN GI distress
18. Thiamine 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Cholangitis
Biliary obstruction (choledocholithiasis)
Secondary Diagnosis:
Esophageal varices, grade I-II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ due to abdominal pain. You underwent
an extensive work-up which found that you had a blockage in your
bile ducts (tubes that carry bile away from the liver) and this
led to an infection. You were given antibiotics and also
underwent a procedure to remove the blockage. You did very well
with this treatment and are now improved enough to return home.
Please be sure to follow-up at the appointments below. If you
develop any fevers, chills, abdominal pain, or other concerning
symptoms, please call your doctor right away.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not operate any vehicles or heavy machinery
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours or as
needed Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic as listed below.
We also generally recommend that patients follow up with their
primary care provider after having surgery.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO BID
5. Calcium Carbonate 500 mg PO TID
6. Citalopram 30 mg PO DAILY
7. Moexipril 15 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Vitamin D ___ UNIT PO DAILY
11. cycloSPORINE *NF* 0.05 % ___ BID
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
advancing dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
You were admitted to ___ for
care of advancing dementia. You will need further outpatient
management to help better care for you at home. It is very
important that you follow up with Dr. ___ ___ at 10am (see contact information below).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Levoxyl (levothyroxine) 75 mcg oral DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1)Left lumbar radiculopathy
2) Meralgia paresthetica or lateral femoral cutaneous neuropathy
is numbness or pain in the outer thigh caused by injury or
irritation to a nerve that extends from the spinal column to the
thigh.
Patient did not have a TIA or STROKE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mrs. ___ you were admitted to ___ for
evaluation of reported left sided sensory changes. You had a
full neurological workup which was negative for stroke and TIA.
We encourage you to continue to take your home medications, no
changes were made to your home medications.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipaton
Discharge Disposition:
Home
Discharge Diagnosis:
appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with abdominal pain. You
underwent a cat scan which showed appendicitis. You were taken
to the operating room to have your appendix removed. You are
recovering from your surgery. You are preparing for discharge
with the following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having abdominal pain.
A CT scan of your abdomen showed some mild inflammation but
otherwise no evidence of a serious acute process. Your blood
tests were all reassuring. It is possible that you have a viral
infection or a small ulcer. You were treated with intravenous
fluids and some medications to settle your stomach.
.
In the emergency department you were also found to have a small
abscess on your abdomen that was drained. You were started on an
antibiotic called clindamycin for this. Please take the entire
course of the medication, even if you start to feel better. If
you experience increasing redness or pain at the site of your
abscess, please call your primary care physician or visit the
Emergency Department.
.
The following changes have been made to your medication regimen
Please START taking
- clindamycin (continue until ___
- omeprazole (to reduce stomach acid)
- maalox (to relief stomach pain and irritation)
.
Please take your medications as prescribed and follow up with
your doctors as ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amitriptyline 50 mg PO QHS
2. Amlodipine 10 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Gabapentin 400 mg PO BID
RX *gabapentin 400 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
6. Labetalol 200 mg PO TID
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Mycophenolate Sodium ___ 360 mg PO BID
RX *mycophenolate sodium 360 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
9. Omeprazole 40 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN Nausea
11. Vitamin D 1000 UNIT PO DAILY
12. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
13. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
14. Atorvastatin 10 mg PO QPM
15. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral daily
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
17. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
RX *albuterol ___ puff IH every 6 hours Disp #*1 Inhaler
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS 1. Acute Kidney Rejection 2. BK nephropathy
and viremia
SECONDARY DIAGNOSIS: 1. Alport Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were initially
admitted to the hospital for concerns about your transplanted
kidney. During your hospital stay, you were given several rounds
of treatment to help prevent rejection of your transplanted
kidney. Unfortunately, with treatment your kidney function began
to worsen and we had to start dialysis. Before leaving the
hospital, we have changed your immunosuppression, and set you up
with dialysis as an outpatient.
You have surgery scheduled for fistula placement on ___,
___. Please arrive at the Main Entrance of the ___
___ at 8:15am. Please do not eat or drink anything past
midnight the night before the procedure.
Many changes were made to your home medication regimen, please
continue to take medications as prescribed. Please follow up
with your primary care physician and your transplant
nephrologist upon leaving from the hospital. We have also set up
appointments for you to meet with the transplant surgery team to
develop long-term solution for your dialysis.
Take Care,
Your ___ Team.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>You were admitted to the hospital after being struck by a car.
You were thrown 20 - 30 feet and lost consciousness. Your
injuries include a left fibula fracture (smaller of the two long
bones connecting your knee to ankle) and a left flank (side)
hematoma. You were admitted to the intensive care unit after
the accident. You were transferred to the floor after you were
assessed to be stable enough for transfer. You are slowly
recovering and will need continuing rehab after your inpatient
stay.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CARVedilol 3.125 mg PO BID
2. Glargine 24 Units Breakfast
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. LevETIRAcetam 750 mg PO BID
4. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7
Days
5. Losartan Potassium 100 mg PO DAILY
6. HELD- Atorvastatin 80 mg PO QPM This medication was held. Do
not restart Atorvastatin until your outpatient provider decides
to restart
7. HELD- GlipiZIDE 10 mg PO BID This medication was held. Do
not restart GlipiZIDE until outpatient provider decides to
restart
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were hospitalized due to symptoms of confusion resulting
from a hemorrhagic STROKE, a condition where there is a bleed in
the brain resulting in parts of the brain not getting enough
oxygen. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms. You then proceeded to have a seizure.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Diabetes
- High blood pressure
We are changing your medications as follows:
- We are stopping your aspirin
- We are holding your atorvastatin
- We added Keppra 750mg BID for seizure prevention
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. doxazosin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
7. diazepam 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Keflex ___ mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
10. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO ___
___: in addition to 4mg tablet for total of 6mg.
12. Outpatient Lab Work
CBC, INR and Chem 7 on ___ and results to be faxed to
___.
Phone: ___
Fax: ___
13. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 packets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Septic shock due to cellulitis and urinary tract
infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with severe infection of your
leg and urine. You were treated in the intensive care unit
followed by treatmet for cellulitis (infection of the leg).
With antibiotics your symptoms improved although significant
amount of swelling and redness in your leg persisted.
You were given water pills to help get rid of some of the water
in your legs. In addition, you required wrapping of your legs
with ACE bandages to help get rid of the fluid.
The following changes were made to your medications.
STARTED:
- Furosemide 20mg daily for one week
- Keflex ___ three times daily
- Potassium 20 meq daily for one week
STOPPED:
- Hydrochlorothiazide
- Lisinopril (until you complete your furosemide)
Please ensure that you elevate your legs daily and wrap them
with ACE bandage.
Should you develop any symptoms concerning to you, please call
Dr. ___, ___ or go to the emergency room.
You have an appointment with Dr. ___ at the end of
___, but his office will contact you to set up a follow up
within the next week. If you don't hear from him by middle of
next week, please call his office.
Please also obtain labs to check your coumadin level next week.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Miconazole Powder 2% 1 Appl TP TID:PRN rash
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
7. Senna 17.2 mg PO HS
8. Spironolactone 25 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Apixaban 5 mg PO BID
11. Aspirin 81 mg PO DAILY heart disease
12. Cyanocobalamin 250 mcg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until your liver function tests
normalize.
15. HELD- MetFORMIN (Glucophage) 850 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until your
doctor tells you to do so.
16. HELD- Metoprolol Succinate XL 100 mg PO BID This medication
was held. Do not restart Metoprolol Succinate XL until your
doctor tells you to do so.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
HFrEF exacerbation
Secondary Diagnoses:
Acute renal failure
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had recent
episode of diarrhea, had fatigue, and were generally feeling
unwell.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You were found to be in hear failure, which led to markedly
reduced the blood perfusion to the vital organs of the body.
-You were given medications to treat heart failure, and to
improve heart function.
-You underwent kidney replacement therapy while in the CCU to
remove excessive fluid
-For atrial fibrillation, you underwent a procedure to change
the rhythm back to normal, but this did not work. Then you had a
procedure to change the electrical conduction in your heart,
which fixed the irregular fast rhythm.
-You were evaluated by physical therapy, who felt that you
should be discharged to a rehab facility for continued therapy.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 139.55 lb. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H:PRN fever, headache
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour apply 1 patch to skin q72 Disp #*15
Patch Refills:*0
5. Gentamicin 240 mg IV Q24H
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Lorazepam 0.5 mg PO HS
RX *lorazepam 0.5 mg 1 tab by mouth at bedtime Disp #*15 Tablet
Refills:*0
8. TraZODone 50 mg PO HS:PRN insomnia
9. Outpatient Lab Work
Weekly OPAT labs: CBC, Chem-7, AST, ALT, AlkPhos, ESR, CRP,
gentamicin trough.
ICD-9: ___
Fax weekly labs to the ___ R.N.s at
___. MD: ___
10. Meropenem 1000 mg IV Q8H Duration: 13 Days
Continue through ___. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Discontinue when INR between ___ x2 days.
12. Warfarin 3 mg PO DAILY
13. Naproxen 500 mg PO Q8H:PRN pain
14. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Acute subsegmental pulmonary embolism
SECONDARY:
-Spinal discitis / osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
chest pain and found to have a small blood clot in your right
lung. You were treated with blood thinners. You were continued
on your antibiotics for your blood and spine infection. You had
an ultrasound of your PICC line to make sure that this was not
the source of the clot in the lung. You also had a
transesophageal echocardiogram which did not show any evidence
of active infection in the heart at this time.
Your antibiotics should continue through ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis, gallstone pancreatitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ on ___ for gallstone
pancreatitis. You received an ERCP with sphincterotomy and
stone removal. You have recovered well and are ready to return
home to continue your recovery there.
MEDICATIONS: Continue all medications you take at home.
ACTIVITY: Continue to follow activity restrictions as
recommended by Dr. ___. Otherwise, you have no restrictions
on your activity.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl [The Magic Bullet] 10 mg 1 suppository(s) rectally
at bedtime Disp #*30 Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
please hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*63 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Compression fracture of L5 and L3 vertebrae
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ after sustaining a fall. Your
injuries were addressed, and you are now ready for discharge.
Activity:
You may perform all your regular activity as tolerated. Please
remember to take pain medicine to make moving easier.
Please call the Orhtopaeidic Spine clinic at ___ if you
develop any numbness, tingling, weakness, pain not relieved by
pain medication, or any other symptoms that concern you.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Apixaban 10 mg PO BID
RX *apixaban [Eliquis] 5 mg ASDIR tablet(s) by mouth twice a day
Disp #*70 Tablet Refills:*0
2. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*3
Capsule Refills:*0
5. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. pimecrolimus 1 % topical BID
9. triamcinolone acetonide 0.5 % topical BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Asthma exacerbation secondary to influenza A
Pulmonary embolus
Secondary Diagnoses
===================
Monoclonal gammopathy of undetermined significance
Multi-nodular thyroid
Gastroesophageal reflux disease
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ because you were having shortness of
breath. You were seen in the emergency room and found to have
the flu along with blood clots in your lungs.
We treated you for a COPD exacerbation exacerbation with
prednisone and azithromycin. We also treated you for the flu
with Tamiflu. You will take each of these medication for a 5 day
course to end on ___.
We started you on a blood thinner medication to treat the blood
clots in your lungs called apixiban. You should take 10mg twice
a day for the next 5 days followed by 5mg twice a day after
that.
You were also found to have high blood pressure in the hospital.
We started you on a medication called lisinopril. You should
continue to take this medication daily until you meet with your
primary care physician.
Please return to the hospital if you have worsening shortness of
breath, fevers, chest pain, or leg swelling.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen (Liquid) 650 mg PO Q8H
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Furosemide 20 mg PO DAILY
5. Ketoconazole 2% 1 Appl TP BID:PRN itching
6. Omeprazole 20 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
9. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
Hold for sedation and RR less than 12
RX *oxycodone 5 mg 1 tablet(s) by mouth every 3 hours Disp #*30
Tablet Refills:*0
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
12. Lidocaine 5% Patch 1 PTCH TD DAILY knee pain
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 2 TAB PO HS
Patient may refuse. Hold if patient has loose stools.
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO Q6H:PRN
nausea or anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Pneumonia, Multiple Myeloma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure taking care of you while you were here at
___. You were admitted after being transferred from an
outside hospital where you were taken after having an episode of
unresponsiveness. You were also having severe back pain. An
MRI of the back was performed which found no acute new lesions
of the spine that would cause the back pain, but did find
infiltration of the bone by myeloma. You had a CT scan of your
head which was normal. You were seen by the oncology team who
indicated that there was no indication to start systemic
treatment. You had a chest CT scan which showed pneumonia and
you were started on antibiotics with a planned course of 8 days,
starting ___. A PICC line was placed so that you could be
discharged with IV antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 600 mg PO DAILY
8. Lidocaine 5% Ointment 1 Appl TP DAILY
9. Lisinopril 10 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Tamoxifen Citrate 20 mg PO DAILY
12. Torsemide 140 mg PO DAILY
13. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==============
Acute influenza A infection
Hypoxemia
Hypernatremia
Altered mental status
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were having fevers.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were diagnosed with acute influenza (the flu).
- You were given medication to help reduce the severity/duration
of your infection.
- You had a CT scan of your brain, which was normal.
- You were given intravenous fluids.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 15 ML by
mouth Every 6 hours Refills:*0
2. lansoprazole 30 mg oral DAILY
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg/5 mL 6.5 ml by mouth Every 6 hours
Refills:*1
4. Bisacodyl 10 mg PO/PR DAILY:PRN c
RX *bisacodyl 10 mg 1 suppository(s) rectally Daily Disp #*12
Suppository Refills:*0
5. Calcium Carbonate 500 mg PO QID:PRN heartburn
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth four times a day Disp #*100 Tablet Refills:*0
6. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour Apply 1 patch Every 72 hours Disp #*5
Patch Refills:*0
7. Hyoscyamine .25 mg PO QID:PRN esophageal secretions
RX *hyoscyamine sulfate 125 mcg/5 mL 10 ml by mouth Four times a
day Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % Apply 1 patch Every evening for 12 hours Disp
#*15 Patch Refills:*0
9. LORazepam 1 mg PO Q8H:PRN anxiety
RX *lorazepam 1 mg 1 mg by mouth Every 8 hours Disp #*21 Tablet
Refills:*0
10. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q3HR:PRN
Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *morphine 10 mg/5 mL 10 mg by mouth Every 3 hours Disp #*500
Milliliter Milliliter Refills:*0
11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth Every 8 hours Disp
#*90 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
Daily Refills:*0
13. Prochlorperazine 10 mg PO Q8H:PRN Nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth Every 8
hours Disp #*30 Tablet Refills:*0
14. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth Nightly Disp
#*30 Tablet Refills:*0
15. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 Tab by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Sucralfate 1 gm PO QID prn pain
RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day
Refills:*0
17. Sumatriptan Succinate 25 mg PO BID:PRN headache
RX *sumatriptan succinate 25 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
18. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Active:
- Radiation esophagitis
- Esophageal cancer s/p XRT
- Nausea with Vomiting
- GERD
- Moderate Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted for treatment and evaluation
of nausea, vomiting and fever shortly after discharge from a
prolonged hospitalization for esophagitis due to treatment of
your cancer. You were restarted on medications to treat your
pain and nausea. You were evaluated by the Palliative Care team
who helped to treat your pain.
Please follow-up with your outpatient providers as instructed
below. You have a follow up in 1 week with oncology. Please try
to cut back on your opiates over the course of the upcoming week
as discussed with the palliative care team. Try not to take more
than 5 doses per day.
Thank you for allowing us to participate in your care. All best
wishes for your health.
Sincerely,
Your ___ medical team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you at ___.
You were admitted for management of infected fluid in your lung.
You received an imaging study (CT Scan) that showed new pockets
of infected fluid in your lung. A medication was placed in your
chest tube to help release this fluid. You will continue your
home antibiotics until your follow-up appointment with the
Infectious Disease clinic. Please also follow-up with your lung
doctors (___) on ___.
Best wishes,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO QHS
4. Clopidogrel 75 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Gabapentin 100 mg PO BID
7. Tolterodine 4 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth once Disp
#*1 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspiration ___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital after vomiting with aspiration
and were treated with antibiotics with improvement in your
symptoms. You experienced some confusion while in the hospital
which improved. You were discharged to ___ for
rehabilitation.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atorvastatin 40 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Outpatient Physical Therapy
Please evaluate and treat.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute to Acute Stroke
History of prior strokes
Seizures
Atrial Fibrillation
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the ___ Inpaitient Neurology Service for
an episode of being unable to speak correctly. You had a
similar episode in ___. At that time, the MRI of your
brain was negative for stroke. However, this time, your MRI
showed a stroke in the left side of your brain in a part called
the temporal lobe. We have continued your blood thiner,
Coumadin, to help prevent further strokes. We have also
continued your cholesterol lowering medication, Atorvastatin.
We have also increased your seizure medication because we are
unsure if your previous episode was a seizure and if you had a
seizure preciptated by a stroke this time. Due to the
possibility of seizures, do not drive for the next 6 months.
Please follow up with your primary care doctor and your
neurologist.
Sincerely,
Your ___ Neurology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Levothyroxine Sodium 75 mcg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Amlodipine 2.5 mg PO DAILY
5. Apixaban 2.5 mg PO BID
6. CeftriaXONE 2 gm IV Q24H
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO DAILY:PRN constipation
11. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
13. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
Please continue through ___. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days
Please continue through ___. Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line
flush
16. Metoprolol Tartrate 12.5 mg PO BID
Please hold for HR <60 or SBP <90
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute issues:
#L elbow necrotizing fasciitis
#A-fib with RVR
#Sinus bradycardia
#Supratherapeutic INR
#new diagnosis systolic CHF
#Leukocytosis
#Normocytic anemia
Chronic issues:
#HTN
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
after you injured your arm and it became infected. You were
treated with antibiotics and had surgical removal of the
infected tissue. We also adjusted the medications you are taking
to prevent strokes. We are discharging you to rehab so that you
can regain your strength.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>___ Tumor
Surgery
聲 You underwent surgery to remove a ___ lesion from your
___.
聲 You may shower at this time but keep your incision site as dry
as possible.
聲 It is best to keep your incision open to air but it is ok to
cover it when outside.
聲 Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
聲 We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your ___ appointment.
聲 You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
聲 No driving while taking any narcotic or sedating medication.
聲 If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
聲 No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
聲 Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
聲 You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
聲 You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
聲 You may experience headaches and incisional pain.
聲 You may also experience some ___ swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
聲 You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
聲 Feeling more tired or restlessness is also common.
聲 Constipation is common. Be sure to drink plenty of fluids and
eat a ___ diet. If you are taking narcotics (prescription
pain medications), try an ___ stool softener.
When to Call Your Doctor at ___ for:
聲 Severe pain, swelling, redness or drainage from the incision
site.
聲 Fever greater than 101.5 degrees Fahrenheit
聲 Nausea and/or vomiting
聲 Extreme sleepiness and not being able to stay awake
聲 Severe headaches not relieved by pain relievers
聲 Seizures
聲 Any new problems with your vision or ability to speak
聲 Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
聲 Sudden numbness or weakness in the face, arm, or leg
聲 Sudden confusion or trouble speaking or understanding
聲 Sudden trouble walking, dizziness, or loss of balance or
coordination
聲 Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Glargine 34 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 40 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Hypertensive Emergency
2. Reduced Ejection Fraction
Secondary
1. Diabetes Mellitus - Type 2, Insulin Dependent
2. Chronic Cough - Secondary to lisinopril
3. Hypertension
4. Hyperlipidemia
5. Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It was a pleasure meeting you during your hospitalization. You
were admitted with forehead pain, blurry vision, and chest pain.
Your symptoms came on very suddenly and seemingly improved with
minimal interventions. Given that your blood pressure was very
high during these symptoms, we believe that you experienced
something called "hypertensive emergency", which means that your
blood pressure was so high that it effected several different
organs in your body. As your blood pressure decreased, your
symptoms of improved. Because you had blurry vision, we
performed a carotid ultrasound which was unremarkable. You had a
stress test which showed that your heart is pumping less
efficiently. You have been scheduled to see a cardiologist on
discharge to discuss how this may be further managed. Your blood
pressure improved without new medications.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 500 mg PO Q6H:PRN pain, fever
2. Aquaphor Ointment 1 Appl TP TID:PRN itchy skin
3. Citalopram 20 mg PO DAILY
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 200 mg PO DAILY
7. Gabapentin 300 mg PO BID
8. HydrOXYzine 25 mg PO Q6H:PRN itcxhing
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Mupirocin Ointment 2% 1 Appl TP TID
11. Nephrocaps 1 CAP PO DAILY
12. Omeprazole 40 mg PO BID
13. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
14. Sarna Lotion 1 Appl TP QID:PRN itchy ksin
15. Senna 8.6 mg PO BID:PRN constipation
16. sevelamer CARBONATE 2400 mg PO TID W/MEALS
17. TraZODone 50 mg PO HS:PRN insomnia
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
19. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN cough
20. ___ Tar (coal tar) 2 % topical HS
21. Nitroglycerin SL 0.4 mg SL PRN chest pain
22. Ondansetron 4 mg PO BID:PRN nausea/vomiting
23. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using lispro Insulin
24. CefTAZidime 2 g IV POST HD
last dose to be given after dialysis on ___
25. Guaifenesin ___ mL PO Q4H:PRN cough
26. Vancomycin 1000 mg IV HD PROTOCOL
last dose to be given after dialysis on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: healthcare associated pneumonia
Secondary: ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted with fevers and cough. You were treated with
antibiotics with improvement in your symptoms. You should
complete a course of antibiotics, which will be given at your
dialysis sessions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ascorbic Acid ___ mg PO BID
RX *ascorbic acid (vitamin C) 250 mg 1 tablet(s) by mouth twice
a day Disp #*60 Tablet Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth once daily Disp #*60 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
once daily Disp #*30 Packet Refills:*0
4. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
5. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once
daily Disp #*14 Capsule Refills:*0
6. Glargine 14 Units Bedtime
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Bisacodyl ___AILY:PRN constipation
12. Fleet Enema (sodium phosphates) ___ gram/118 mL rectal
DAILY:PRN
13. Fluticasone Propionate 110mcg 1 PUFF IH BID
14. GuaiFENesin 10 mL PO Q6H:PRN cough
15. Milk of Magnesia 30 mL PO DAILY:PRN constipation
16. Mirtazapine 15 mg PO QHS
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Senna 8.6 mg PO DAILY
19. Sertraline 12.5 mg PO DAILY
20. Sodium Bicarbonate 650 mg PO BID heartburn
21. Sorbitol 30 mL PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
==================
Primary Diagnosis
==================
Lower GI bleed secondary to stercoral ulcer
===================
Secondary Diagnosis
===================
Anemia secondary to acute blood loss
Ascending colon polyp
Hypernatremia
Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You had blood in your stool and required blood transfusions
for low blood counts
What was done while I was in the hospital?
- You were given blood transfusions for low blood counts
- A camera was used to check your GI tract for bleeding and
you were found to have an ulcer in your colon which was likely
the source of your bleeding. It was not bleeding so no further
procedures needed to be done
What should I do when I go home?
- It is very important that you take your medications as
prescribed
- Please go to your scheduled appointment with your GI doctor
and are seen by the primary doctor at your extended care
facility.
- If you have more blood in your stool and black tarry stool,
please tell your primary doctor or go to the emergency room.
Best wishes,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Calcium Carbonate 500 mg PO QID:PRN heartburn
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroenteritis
Mild demand ischemia
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were transferred to ___ for viral gastroenteritis. This
improved, but you were also found to have some mild injury to
your heart, some enlargement of your bile ducts, gallstones and
sludge in your gallbladder, and also a GI bleed. The GI bleed
resolved and you underwent endoscopy which showed diverticulosis
which is the likely cause of bleed.
The other issues can be examined as an outpatient. You will need
some cardiac testing to evalute the health of your heart and an
MRI of your liver to evaluate for the enlargement of your bile
duct in the area of the left portion of your liver. You also
had mildly elevated LFTs on the day prior to and after
discharge. You should have repeat lipase and LFTs at your
follow up appt.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 70 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*60 Syringe Refills:*0
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN dyspnea
RX *hydromorphone 2 mg 1 tablet(s) by mouth q4h prn Disp #*12
Tablet Refills:*0
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Pantoprazole 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. PredniSONE 80 mg PO DAILY
10. Senna 8.6 mg PO DAILY
11. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Aspirin 81 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Levothyroxine Sodium 100 mcg PO DAILY
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
18. Simvastatin 10 mg PO QPM
19. Vitamin D ___ UNIT PO DAILY
20. HELD- Dexamethasone 4 mg PO DAILY This medication was held.
Do not restart Dexamethasone until you follow-up with your
Oncologist.
21. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you f/u with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Drug induced pneumonitis
Acute Hypoxic Respiratory Failure
Secondary:
Anxiety
Pulmonary Embolism
Metastatic Lung Adenocarcinoma
Steroid-Induced Hyperglycemia
Hyponatremia
Leukocytosis
Anemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had fever,
shortness of breath, and cough and were found to have a drug
reaction called Pneumonitis. This was from the Pembrolizumab you
received.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received a breathing tube for several days to help you
breathe.
- You received steroids to decrease the inflammation in your
lungs (pneumonitis) and a medicine called IVIG.
- You were found to have a blood clot (pulmonary embolism) and
you were started on blood thinners (anticoagulation).
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Go to your appointment with your Oncologist.
- Go to your appointment with the pulmonologists.
- Follow-up with Palliative Care - if you are at rehab and are
having difficulty finding a palliative care doctor for support,
please contact Dr. ___ or contact Dr. ___
the number he left you in his card.
We wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 10 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*15
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R SDH
R olecranon fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity status: ambulatory- independent
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the ACS service for your injuries, which
included bleeding in your head and an elbow fracture. You are
ready to continue your recovery at home. Please resume all home
medications. You may take tylenol or motrin for pain control and
narcotic medication if needed, and only as directed. You can
continue on a regular diet. You may resume all your usual
activities. Keep your R elbow in a splint and keep the R arm as
non-weight-bearing until you follow-up with orthopedic surgery.
You may do passive range of motion exercises with that arm.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Simvastatin 10 mg PO DAILY
2. Furosemide 10 mg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Aripiprazole 2 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ciprofloxacin HCl 250 mg PO Q12H
9. Losartan Potassium 50 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal ___ drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Please abstain from taking Plavix until you follow up with
Neurosurgery in clinic in 4 weeks.
Please take a full liquid (non-chew) diet for the next two weeks
or until you follow up with a dentist for definitive dental care
regarding your tooth injury.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Baclofen 10 mg PO TID as needed for pain
4. Carbamazepine (Extended-Release) 200 mg PO BID
5. Colchicine 0.6 mg PO EVERY OTHER DAY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO MORNING, NOON
8. Gabapentin 1200 mg PO HS
9. Glargine 20 Units Bedtime
10. Metoprolol Tartrate 25 mg PO Q 8H
11. Tamsulosin 0.4 mg PO HS
12. Warfarin 7.5 mg PO DAILY16 afib, home med
please adjust your coumadin dose according to your INR checks at
___ via Dr ___
13. Zolpidem Tartrate 5 mg PO HS insomnia
**** INSTRUCTED TO CONTINUE ALL HOME MEDS UNLESS INSTRUCTED
OTHERWISE BY PCP***
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Ischemic Attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You were admitted for symptoms of left hand and leg weakness
which had resolved prior to your arrival. Your head imaging was
negative for stroke, so you likely had a "TIA" which stands for
transient ischemic attack. Please follow up with your Atrius
doctor and have him set you up with an Atrius Neurologist for
follow up. We have not changed any of you medications so you
should continue to take all of your home medications as
instructed by your primary doctor.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- obstructive uropathy
SECONDARY DIAGNOSES
- hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to meet you and your family. You were admitted
because you were confused. This was because your prostate was
blocking urine from leaving your bladder and so your
electrolytes and toxins were building up in your body. You had
dialysis to improve your electrolyte balance, and placed a foley
catheter to drain the urine. You were feeling better, and were
able to be discharged.
You will need to follow-up with the urology team to talk about
the next steps so that this does not happen again.
Please see below for more information about any changes made to
your medications.
Again, it was very nice to meet you, and we wish you the best.
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. DME
Straight cane
dx: CAD, s/p CABG
prognosis: good
length of need: 13 months
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Furosemide 40 mg PO DAILY
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
6. HydrALAZINE 10 mg PO Q8H
RX *hydralazine 10 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*1
7. Humalog ___ 30 Units Breakfast
Humalog ___ 14 Units Dinner
8. Sertraline 150 mg PO DAILY
9. Docusate Sodium 100 mg PO BID Duration: 2 Weeks
10. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q 3
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage. Edema trace
Followup Instructions:
___ [/INST] </s><s>Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Bisacodyl 10 mg PO DAILY:PRN c
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Jevity 1.5 Cal (lactose-reduced food with fibr) 240 ml can
oral ASDIR
1 can (240 mL) five times daily
RX *lactose-reduced food with fibr [___ 1.5 Cal] 0.06
gram-1.5 kcal/mL 1 can G tube ASDIR Disp ___ Milliliter
Milliliter Refills:*0
3. LORazepam 0.5 mg PO TID:PRN nausea
try reglan (metoclopramide) first
RX *lorazepam 0.5 mg 1 tablet by mouth three times a day Disp
#*10 Tablet Refills:*0
4. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth four times a day
Disp #*90 Tablet Refills:*3
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*3
6. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day
Refills:*3
7. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice daily Disp #*30 Packet Refills:*3
8. Senna 8.6 mg PO QHS
RX *sennosides [senna] 8.6 mg 1 tab by mouth every night Disp
#*30 Tablet Refills:*3
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every 12
hours Disp #*30 Tablet Refills:*0
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
11. Ranitidine 75 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Squamous cell carcinoma of the soft palate, uvula and
tonsils, moderate malnutrition, Dehydration, anxiety
SECONDARY: Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital with
dehydration and malnutrition. After discussion with your
outpatient oncologist, radiation oncologist and family, the
decision was made to place a device called a "percutaneous
enteral gastrostomy tube," or G-tube, for providing nutrition
until you complete your course of radiation and chemotherapy.
You were started on continuous tube feeds which you tolerated
well, and then you were transitioned to bolus tube feeds. We
also increased your dose of oxycontin to better control your
pain, and we started two new medications for nausea (reglan,
also called metoclopramide, and ativan, also called lorazepam).
When you go home, you are going to administer 1 can of Jevity
1.5 through your G-tube five times per day. You will have a
visiting nurse who will help you to do this at home, and your
family will also assist you.
Thank you for allowing us to participate in your care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
last day last ___ in the am
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Senna 17.2 mg PO QHS:PRN constipation
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. BuPROPion 150 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Scopolamine Patch 1 PTCH TD Q72H
10. Tamsulosin 0.4 mg PO QHS
11. Thiamine 100 mg PO DAILY
12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
13. TraZODone 25 mg PO QHS
14. TraZODone 25 mg PO Q6H:PRN anxiety / agitation
15. HELD- Atorvastatin 20 mg PO QPM This medication was held.
Do not restart Atorvastatin until you have your liver enzymes
rechecked in about 1 week
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
gallstone pancreatitis
choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with a gallstone blocking your biliary duct, and inflammation in
your pancreas (pancreatitis). You were seen by GI specialists
and underwent a special kind of endoscopy (ERCP) where a stone
was removed from your gallbladder. You will need to take an
antibiotic called cipro for 5 days after your ERCP and to see
the surgery team in clinic to discuss options for gallbladder
removal surgery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
4. nafcillin 2 gram injection Q 4 hrs
thru ___
RX *nafcillin 2 gram 2 Gm IV every four (4) hours Disp #*38 Vial
Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
6. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MSSA anterior mediastinal abscess
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>* You were admitted to the hospital for evaluation of your chest
and back pain which ultimately was due to an infected mass ___
your anterior mediastinum. You eventually required surgery and
you've recovered well. You are now ready for discharge but will
need antibiotics at home until ___. The Infectious Disease
service will continue to follow you as an out patient.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours ___ between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions.
* Your kidney function was initially abnormal probably due to
the use of Ibuprofen prior to admission and multiple contrast
studies while hospitalized. Your kidney function is improving
daily but you cannot take Ibuprofen and should not have any
studies with contrast until your kidneys have time to heal and
function properly. It is important for your kidneys to stay well
hydrated too.
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atenolol 100 mg PO DAILY
2. CloniDINE 0.2 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Ranitidine 75 mg PO DAILY
RX *ranitidine HCl [Acid Control] 75 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 g by
mouth daily Disp #*30 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: constipation, abdominal pain, possible alcohol
gastritis
secondary: alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You came to the hospital because of chest pain and abdominal
pain. You had imaging done of your abdomen which showed you are
constipated. It is most likely your abdominal pain is from
constipation and also from drinking alcohol. We recommend you
stop drinking alcohol, follow up with your primary care doctor
___ below for appointment times). You may need a scope (a
camera that goes down your throat to look at your stomach) to
see if you have any inflammation of your stomach from alcohol</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Clobazam 20 mg PO QHS
2. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder
3. TraZODone ___ mg PO QHS:PRN insomnia
4. ZOLMitriptan 5 mg nasal ASDIR
5.Outpatient Physical Therapy
Cervical musculoskeletal pain
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
You were admitted to the neurology service for symptoms of left
arm weakness which was concerning for stroke. Your brain MRI was
normal and did not show any stroke or other abnormalities. On
examination, you did not have physiologic weakness. We
recommended a cervical soft-collar for your neck pain which was
exacerbating your headache. You were seen by physical therapy
who recommended outpatient ___.
Please follow-up with Dr. ___ as already scheduled.
Best,
Your ___ Neurology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Chlorthalidone 50 mg PO DAILY
4. colestipol 2 grams oral daily
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Glargine 26 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Portal vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ was a pleasure taking care of you here at ___. You were
admitted to the hospital for a clot in a blood vessel in your
liver called the portal vein. You were evaluated by the liver
specialists who do not feel you need blood thinners for this. We
recommend that you followup with the liver tumor clinic to
further discuss treatment of your liver cancer.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Fluoxetine 10 mg PO DAILY
4. Repaglinide 0.5 mg PO TIDAC
5. Lorazepam 0.5 mg PO BID PRN vertigo
6. Restasis (cycloSPORINE) 0.05 % ophthalmic BID left eye
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
9. Outpatient Physical Therapy
ICD-9-CM 438.85 Vertigo
Will need ___ rehab.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: chronic vertigo, cervical stenosis, macular
degeneration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were hospitalized due to worsening unsteadiness and
dizziness. These symptoms represent a worsening of your chronic
vertigo due to your right ear surgery. As you were found to have
decreased vibration and position sense in your legs, we also
checked a cervical spine MRI. This did show some degenerative
changes (arthritis) in your neck and narrowing of the spinal
canal, but there was no compression.
Physical therapy worked with you in the hospital and recommended
discharge home with outpatient ___ rehab and physical
therapy. You have a prescription for this. Please call the
numbers for home care services.
Please follow-up with your primary care doctor within 1 week.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right middle cerebral artery stroke.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neuro examination at discharge:
Patient demonstrated wakefulness, attention, and improved speech
daily. She remains hemiplegic on the left with no movement on
the L side even to noxious stimuli. There is a left facial
droop. Reflexes are brisk, and upgoing on the left plantar. She
is inattentive to her left side. Mentation and mood are off for
the circumstance.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
You were admitted to ___ after
imaging done at your local ___ showed that you had suffered
a large stroke. The stroke was in the middle cerebral artery in
your brain on the right side. This is a very serious medical
condition, and your recovery will likely be a long one, but
since you are so young, your prognosis to regain some
functioning is very good.
.
It is very important that you take all of your medications as
prescribed especially the aspirin. Additionally, you MUST stop
smoking. It places you at a very high risk of having another
stroke. People who are trying to quit smoking have the best
success when they surround themselves with supportive people who
also do not smoke. If you need a Nicotine patch, Nicorette gum,
or other nicotine supplements, please ask your doctor at rehab
to help you attain some.
.
When you were medically stable to leave the hospital, you were
discharged to a rehab facility where you can have more intensive
physical, occupational, and speech therapy.
.
It was very nice to meet you and your family. We wish you the
very best in your recovery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. PredniSONE 20 mg PO DAILY Duration: 3 Doses
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
3. PredniSONE 10 mg PO DAILY Duration: 2 Days
4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Aspirin 81 mg PO DAILY
7. FLUoxetine 40 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nicotine Patch 21 mg TD DAILY
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs BID for wheezing
14. Thiamine 100 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Moderate to severe stenosis of bio-prosthetic aortic valve
- Non-ST segment elevation myocardial infarction
- Chronic obstructive pulmonary disease
- Depression
- Hypothyroidism
- Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
WHY WERE YOU ADMITTED?
- You had chest pain and shortness of breath
WHAT WAS DONE?
- You were observed while exercising to see how well your heart
could handle it
- We found that your valve that was replaced recently has become
narrowed and is the reason for your symptoms
WHAT TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please follow up with your doctor appointments as listed below
- Your outpatient cardiologist (heart doctor) will tell you the
next steps to fixing your valve
- If you have the SAME chest pain (that hurts when you push on
it), you can take Tylenol Extra-Strength 2 tablets (1,000 mg)
every 8 hours as needed.
- If you have any NEW chest pain or chest pressure, shortness of
breath, or sudden weight gain, please call a doctor.
It was a pleasure taking care of you,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Tamsulosin 0.4 mg PO HS
2. PredniSONE 5 mg PO DAILY
3. Pravastatin 10 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Glargine 7 Units Breakfast
7. Furosemide 120 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the transplant surgery service for
observation in the setting of increased abdominal pain and
diarrhea. Your pain resolved shortly after admission and you are
tolerating your tube feeds without pain or nausea. Your stool
was checked for infection and was negative and your diarrhea has
also resolved. You are safe to return home and continue your
tube feed and dialysis regimen.
If you experience worsening abdominal pain, nausea, vomiting,
fevers, chills, significant diarrhea, or other symptoms that
concern you please call the Transplant Surgery Office at
___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Captopril 50 mg PO TID
4. Digoxin 0.125 mg PO DAILY
5. Dipyridamole-Aspirin 1 CAP PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Simvastatin 10 mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Amitriptyline 25 mg PO HS
12. Clonazepam 0.25 mg PO QHS:PRN insomnia
This medication will be tapered and discontinued as an
outpatient.
13. GlipiZIDE XL 2.5 mg PO DAILY
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Confusion, self-resolved, possibly medication effect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ after you were found to be fatigued
and a little confused. You underwent an evaluation including
physical exams, blood tests, and CT scan of the head. Based on
this work-up, there were no worrisome findings. Your symptoms
were most likely due to medications. We have changed around some
of the medicines to try to help prevent this from happening in
the future.
If you begin to experience any worrisome symptoms such as
confusion, dizziness, lightheadedness, falls, or any other
concerning symptoms, please call your doctor right away.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic three
times a day.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic daily ().
6. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic twice a day.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. hydrocortisone-pramoxine ___ % Cream Sig: One (1) Topical
once a day as needed for itching.
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day): MWF ___.
13. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day): ___, Th, ___.
14. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: ___ Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
15. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
16. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
17. sirolimus 1 mg Tablet Sig: 1.5 Tablets PO q am.
18. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
19. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a
day.
20. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
21. triamcinolone acetonide 0.1 % Cream Sig: One (1) Topical
once a day: apply to itchy skin, no longer than 2 wks at a time.
22. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H
(every 48 hours) as needed for peripheral neuropathy.
23. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO
twice a day.
25. senna 8.6 mg Capsule Sig: Two (2) Capsule PO at bedtime:
hold for loose stool.
26. ceftazidime 1 gram Recon Soln Sig: ___ g Intravenous with
dialysis for 9 days: Pt is to receive ___ w/ HD until ___.
Disp:*qs g* Refills:*0*
27. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
28. insulin regular human 100 unit/mL Solution Sig: as directed
Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
E coli septicemia (suspected HD line infection)
Secondary:
s/p pancreas and renal transplant
chronic renal failure
diastolic and systolic congestive heart failure
severe mitral regurgitation
peripheral neuropathy
glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital for fevers and rigors during
dialysis. You were found to have a bacterial infection in your
blood and were started on broad-spectrum antibiotics. You then
became septic, had low blood pressure, and were transferred
briefly to the ICU, where you were given fluids and started on
high-dose steroids. Your dialysis line was also pulled because
it may have been the cause of your infection. Your urine did not
show any sign of infection, nor did your chest X-ray. Your
echocardiogram did not show any signs of endocarditis, but your
prior mitral regurgitation has worsened to severe and your
pulmonary hypertension is also worse. When you first came, you
developed right leg pain of unclear etiology. This may have been
due to low blood pressure from sepsis worsening your baseline
poor leg perfusion from your peripheral vascular disease. You
also developed some shortness of breath, likely because you were
fluid overloaded. Your symptoms resolved after you had a new
dialysis catheter placed and were dialyzed. Your blood cultures
eventually grew E coli. You were initially treated with
meropenem, but this was switched to ceftazidime with
hemodialysis to avoid putting another line and potential source
of infection. Although you had a potential drug reaction to a
cephalosporin causing neutropenia, our infectious disease
experts felt that treatment with ceftazidime was the preferred
option due to your brief treatment course of 2 weeks, no need of
another line, and no renal toxicity (as with gentamicin). Your
blood levels will be closely monitored to ensure that you do not
develop neutropenia. Your stool sample was negative for C diff
infection.
We have made the following changes to your medications:
-START ceftazidime 2g/2g/3g with hemodialysis until ___.
-INCREASE sevelamer to 1600mg three times daily with meals
Please continue to take your other medications as previously
prescribed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*26 Tablet Refills:*0
2. Phenazopyridine 100 mg PO TID Duration: 3 Days
It may turn your urine orange. You can only take this for three
days
RX *phenazopyridine [Uristat] 95 mg 1 tablet(s) by mouth three
times a day Disp #*9 Tablet Refills:*0
3. Orsythia (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg oral
daily
4. Promethazine 12.5 mg PO Q6H:PRN nausea
RX *promethazine 12.5 mg 1 tablet(s) by mouth three times a day
Disp #*10 Tablet Refills:*0
5. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
It may make you drowsy
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg 1
tablet(s) by mouth every 6 hours as needed for pain Disp #*10
Tablet Refills:*0
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg ___
tablet(s) by mouth every 6 hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ because of pain in your abdomen and
nausea and vomiting. You were diagnosed with pyelonephritis
(infection of the kidneys that occurs because the urine is
infected). Please finish a 14 day course of antibiotics for
this. Also, you may take the medication pyridium for up to
three days to help with symptoms of bladder spasm. I have also
given you a prescription for medication for nausea in case you
need something. You may also take tylenol with codeine for your
back pain from your kidney infection. Your antibiotics reduce
the efficacy of your birth control pills in their ability to
prevent pregnancy; if you are sexually active for the rest of
this pack of pills make sure that your partner uses a condom.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. DiphenhydrAMINE 50 mg PO Q6H:PRN Insomnia
2. Famotidine 20 mg PO DAILY
3. LamoTRIgine 150 mg PO QHS
4. LevETIRAcetam 1000 mg PO QHS
5. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Active:
- Acute idiopathic pancreatitis
- Chronic Pancreatic Insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms ___,
It was a pleasure treating you during this hospitalization. You
were admitted for pancreatitis. You were seen by the Pancreas
doctors and ___ surgery. With time and conservative
care your pancreatitis resolved and by discharge you were
tolerating a regular diet.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q8H Duration: 6 Days
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
3. CeftriaXONE 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV Q24h
Disp #*6 Intravenous Bag Refills:*0
4. PredniSONE 10 mg PO ONCE Duration: 1 Dose
30mg ___, 20mg ___, 10mg ___
Tapered dose - DOWN
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pasteurella epiglottitis
Pasteurella bacteremia
Primary herpes simple I infection
Secondary diagnosis:
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted with throat pain and
were found to have epiglottis and a blood stream infection
caused by the bacteria, Pasteurella. We believe your dog
transmitted this infection to you. You were initially admitted
to the ICU and required a breathing tube. After treatment with
antibiotics, you improved and transitioned to the general
medicine floor. Our infectious disease colleagues evaluated you
and recommended a 14 day course of ceftriaxone, an IV
medication. You should have home infusions of this medication
daily through ___.
You were also found to have a primary herpes simplex I infection
of your mouth. You were started on acyclovir, which you should
continue to take for a total of 7 days (day 1: ___, day 7:
___.
You should follow-up with the ear, nose, and throat doctor, ___.
___ in ___ weeks. Please call ___ to make an
appointment. You have an appointment with your PCP, ___,
___ for ___ at 9:20am.
Please take care,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Multivitamins 1 TAB PO DAILY
4. beclomethasone dipropionate 80 mcg/actuation inhalation
BID:PRN SOB
5. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN hand rash
6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 14 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left third finger flexor tenosynovitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted for pain and swelling of your left hand. You
were seen by the hand surgery team. You were put on IV
antibiotics and your symptoms improved. You had a possible
allergic reaction or side effect to Vancomycin which caused
tingling in your throat. Please continue antibiotics and
follow-up in the hand surgery clinic as scheduled.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Outpatient Lab Work
please check INR on ___ and fax results to:
Name: ___.
Location: ___
Address: ___, ___
Phone: ___
Fax: ___
and
___ clinic
Fax: ___
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX ___ 800 ___ mg 1 (One)
tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0
3. Atenolol 100 mg PO DAILY
4. Doxycycline Hyclate 100 mg PO Q12H
5. Finasteride 5 mg PO DAILY
6. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr ___,
You were admitted to the hospital because of a fall. You
evaluation showed no heart attack, stroke, bleeding in your
brain, or abnormal heart rhythm as the cause of your fall. Your
fall was likely related to a urinary tract infection, for which
you will need to complete a course of antibiotics. You were
evaluated by ___, who felt that you would benefit from home ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. enalapril maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with appendicitis requiring an
operation to remove your appendix. You are being discharged to
home with the following instructions: You are being discharged
on medications to treat the pain from your operation. These
medications will make you drowsy and impair your ability to
drive a motor vehicle or operate machinery safely. You MUST
refrain from such activities while taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care: You may shower, no tub baths or swimming. If there
is clear drainage from your incisions, cover with clean, dry
gauze. Your steri-strips will fall off on their own. Please
remove any remaining strips ___ days after surgery. Please call
the doctor if you have increased pain, swelling, redness, or
drainage from the incision sites.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
You were found down unresponsive on the side walk after drinking
alcohol and taking suboxone. You required support of your
breathing because of this. It is very important that you do not
take this combination of medications again in the future as it
can make you stop breathing and kill you. We are happy that you
improved and are ok. It was a pleasure being involved in your
care.
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*24 Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
3. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ranitidine 150 mg PO BID
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
9. Outpatient Lab Work
Please draw CBC + diff on ___ and fax results to Dr. ___
___ at ___. ICD 9: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
anaplasma
lymphadenopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was our pleasure participating in your care. You were
admitted on ___ after being found to have blood in your
stool. You were found to have low blood and platelet counts but
fortunately did not need any blood transfusions. On evaluation
of your low counts, you were found to have large abdominal lymph
nodes concerning for lymphoma. You were also found to have an
infection, called anaplasmosis, for which you were started on an
antibiotic. .
You also underwent bone marrow biopsy. The results of this are
currently pending. You will be called when these results are
finalized.
Your platelets have remained low and puts you at risk for
bleeding. Please let your doctor know if you develop any
headaches, bleeding of your gums or nose bleeds or other
episodes of black stool or bleeding. You will need to get your
blood drawn on ___ to check your blood count.
Again, it was our pleasure participating in your care,
Your ___ Team</s> |